Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
Mount Auburn Hospital, Cambridge, MA.
Acad Emerg Med. 2018 Sep;25(9):980-986. doi: 10.1111/acem.13430.
Data are lacking on how emergency medicine (EM) malpractice cases with resident involvement differs from cases that do not name a resident.
The objective was to compare malpractice case characteristics in cases where a resident is involved (resident case) to cases that do not involve a resident (nonresident case) and to determine factors that contribute to malpractice cases utilizing EM as a model for malpractice claims across other medical specialties.
We used data from the Controlled Risk Insurance Company (CRICO) Strategies' division Comparative Benchmarking System (CBS) to analyze open and closed EM cases asserted from 2009 to 2013. The CBS database is a national repository that contains professional liability data on > 400 hospitals and > 165,000 physicians, representing over 30% of all malpractice cases in the United States (>350,000 claims). We compared cases naming residents (either alone or in combination with an attending) to those that did not involve a resident (nonresident cohort). We reported the case statistics, allegation categories, severity scores, procedural data, final diagnoses, and contributing factors. Fisher's exact test or t-test was used for comparisons (alpha set at 0.05).
A total of 845 EM cases were identified of which 732 (87%) did not name a resident (nonresident cases), while 113 (13%) included a resident (resident cases). There were higher total incurred losses for nonresident cases. The most frequent allegation categories in both cohorts were "failure or delay in diagnosis/misdiagnosis" and "medical treatment" (nonsurgical procedures or treatment regimens, i.e., central line placement). Allegation categories of safety and security, patient monitoring, hospital policy and procedure, and breach of confidentiality were found in the nonresident cases. Resident cases incurred lower payments on average ($51,163 vs. $156,212 per case). Sixty-six percent (75) of resident versus 57% (415) of nonresident cases were high-severity claims (permanent, grave disability or death; p = 0.05). Procedures involved were identified in 32% (36) of resident and 26% (188) of nonresident cases (p = 0.17). The final diagnoses in resident cases were more often cardiac related (19% [21] vs. 10% [71], p < 0.005) whereas nonresident cases had more orthopedic-related final diagnoses (10% [72] vs. 3% [3], p < 0.01). The most common contributing factors in resident and nonresident cases were clinical judgment (71% vs. 76% [p = 0.24]), communication (27% vs. 30% [p = 0.46]), and documentation (20% vs. 21% [p = 0.95]). Technical skills contributed to 20% (22) of resident cases versus 13% (96) of nonresident cases (p = 0.07) but those procedures involving vascular access (2.7% [3] vs 0.1% [1]) and spinal procedures (3.5% [4] vs. 1.1% [8]) were more prevalent in resident cases (p < 0.05 for each).
There are higher total incurred losses in nonresident cases. There are higher severity scores in resident cases. The overall case profiles, including allegation categories, final diagnoses, and contributing factors between resident and nonresident cases are similar. Cases involving residents are more likely to involve certain technical skills, specifically vascular access and spinal procedures, which may have important implications regarding supervision. Clinical judgment, communication, and documentation are the most prevalent contributing factors in all cases and should be targets for risk reduction strategies.
缺乏关于涉及住院医师的急诊医学（EM）医疗事故案例与不指名住院医师的案例有何不同的数据。
本研究旨在比较有住院医师参与的医疗事故病例（住院医师病例）与不涉及住院医师的病例（非住院医师病例）的特征，并确定利用急诊医学作为其他医学专业医疗事故索赔模型的因素。
我们使用了 CRICO 策略公司（CRICO）比较基准系统（CBS）的数据来分析 2009 年至 2013 年期间提出的开放和关闭的 EM 案例。CBS 数据库是一个国家数据库，包含了 400 多家医院和 16.5 万多名医生的专业责任数据，占美国超过 35 万索赔的 30%以上（>35 万索赔）。我们比较了指名住院医师（单独或与主治医生一起）的病例和不指名住院医师的病例（非住院医师队列）。我们报告了病例统计数据、指控类别、严重程度评分、程序数据、最终诊断和促成因素。使用 Fisher 确切检验或 t 检验进行比较（alpha 设置为 0.05）。
共确定了 845 例 EM 病例，其中 732 例（87%）未指名住院医师（非住院医师病例），而 113 例（13%）指名住院医师（住院医师病例）。非住院医师病例的总损失更高。在两个队列中，最常见的指控类别是“诊断/误诊的延误或失败”和“医疗处理”（非手术程序或治疗方案，即中心静脉置管）。在非住院医师病例中发现了安全和保障、患者监测、医院政策和程序以及违反保密规定的指控类别。住院医师病例的平均支付额较低（每例 51163 美元对 156212 美元）。66%（75 例）的住院医师病例和 57%（415 例）的非住院医师病例为高严重程度索赔（永久性、严重残疾或死亡；p=0.05）。在 32%（36 例）的住院医师病例和 26%（188 例）的非住院医师病例中确定了程序（p=0.17）。住院医师病例的最终诊断更常与心脏有关（19%[21]与 10%[71]，p<0.005），而非住院医师病例的最终诊断更常与骨科有关（10%[72]与 3%[3]，p<0.01）。住院医师和非住院医师病例中最常见的促成因素是临床判断（71%对 76%[p=0.24]）、沟通（27%对 30%[p=0.46]）和文档（20%对 21%[p=0.95]）。技术技能导致 20%（22 例）的住院医师病例和 13%（96 例）的非住院医师病例（p=0.07），但涉及血管通路（2.7%[3]与 0.1%[1]）和脊柱手术（3.5%[4]与 1.1%[8]）的程序在住院医师病例中更为常见（每个病例均 p<0.05）。
非住院医师病例的总损失更高。住院医师病例的严重程度评分更高。住院医师病例和非住院医师病例的整体病例特征，包括指控类别、最终诊断和促成因素相似。涉及住院医师的病例更有可能涉及某些技术技能，特别是血管通路和脊柱手术，这可能对监督有重要影响。临床判断、沟通和文档是所有病例中最常见的促成因素，应成为降低风险策略的目标。
