U.S. Department of Health and Human Services
Indian Health Service: The Federal Health Program for American Indians and Alaska Natives
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RISK MANAGEMENT

Lessons Learned from the IHS and Tribal Health Care

Medical Malpractice Tort Claim Experience Article sections:

Methods

The were a total of 1,444 cases of alleged medical malpractice in the database from FY 1987 through FY 2006. The database query feature was used to extract and compile the data of interest, and in turn this information was transferred to a spreadsheet for manipulation and tallying. The most common examples of each allegation category were determined by examining the allegation text entry for each claim. Information on the number and types of IHS and tribal facilities was provided by the Office of Clinical and Preventive Services, IHS Headquarters.

Allegation Classification. When a tort claim is entered into the RMP database, the claim allegation is classified using one of eight categories.  Table 1 shows the number and percentage of tort claim cases within each category, listed in descending order of prevalence.

Table 1. Number and percentage of FY 1987–2006 tort claim cases classified by allegation category

Allegation Class Number Percent

Diagnosis-related

523

36.2%

Treatment-related

332

23.0%

Surgery-related

249

17.2%

Perinatal care-related

142

9.8%

Medication-related

90

6.2%

Dental-related

50

3.5%

Other

49

3.4%

Anesthesia-related

9

0.6%

The most common allegation type was the alleged failure to timely or properly diagnose a condition, which accounted for 36% of cases. The most common examples included missed/delayed diagnosis of a cancer, an infectious disease (such as meningitis, sepsis, or pneumonia), an acute coronary event, an acute abdomen (especially appendicitis), and bone and joint injuries. The next most common allegation type was the alleged failure to timely or properly treat a condition, representing 23% of cases. In this category, the most common entities included the improper management of an infectious condition, traumatic injuries including wounds with retained foreign bodies (e.g., glass or wood fragments), respiratory illnesses such as asthma or pneumonia, and gastrointestinal illnesses including gall bladder disease. Since many tort claims allege both the failure to timely or properly diagnose and treat, these two categories overlap considerably. Combined, they accounted for 59% of all cases.

The surgery classification refers to cases that involved an allegation of improper surgical intervention or peri-operative care (excluding obstetrical surgeries). These cases accounted for 17% of the total cases. The most frequent conditions included damage to the biliary ducts during gall bladder surgery (primarily laparoscopic), improper surgical management of orthopedic conditions, improper surgical management of other abdominal conditions such as colon surgery or appendectomy, and retained foreign bodies at surgery (primarily surgical sponges).

Cases alleging improper perinatal care (during the prenatal, labor, delivery, and post-partum periods) accounted for 10% of cases. Most commonly, this included improper labor management with an inadequate assessment of fetal wellbeing. Other examples relate to the improper choice of delivery method, failure to properly perform a delivery, and improper prenatal care with inadequate assessment of fetal wellbeing.

The medication-related category refers to the alleged improper prescribing or dispensing of a drug, or the alleged adverse reaction to a drug. These accounted for 6% of the total cases. The most common examples included the wrong medication prescribed (often related to not assessing drug allergies) and dispensing errors.

The dental category reflects care provided by dental clinic staff, primarily dentists and oral surgeons. These cases accounted for 3.5% of total cases. Common examples include the alleged improper performance of extractions resulting in complications, infections as a consequence of various dental procedures, and the wrong tooth being extracted.

The “other” category was used to classify cases that did not fit into any of the specific categories; these accounted for 3% of cases. Examples included allegations related to the response from emergency medical services, a delay in or failure to transport, and the failure to properly monitor or care for a patient resulting in injury-sustaining falls.

Only nine cases (less than 1% of the total) had been coded as anesthesia-related, most having to do with airway management at the time of surgery. Two others involved the use of fluids or sedation during surgery, and another two involved alleged complications from spinal anesthesia. It should be noted that there were several surgery and perinatal cases where a component of the allegation also referred to anesthesia-related issues.

Injury Classification. Knowledge of the degree of the alleged injuries provides an appreciation for the severity of the adverse outcomes that resulted in a tort claim being filed. Table 2 shows the number and percentage of cases for each alleged injury type, in order of decreasing prevalence. The most common injury class was permanent physical injury, which accounted for 39% of the cases. Second was death, with 29%, then temporary physical injury with 26% of cases. Non-physical injury accounted for less than 4% of cases; this code was used for cases alleging primarily psychological harm or purely economic damages. The undetermined injury category was used for cases where the alleged injury was unclearly stated or could not specifically be determined from a review of the available material. Three cases involved wrongful birth injury, alleging improper management of contraceptives or improper performance of a sterilization procedure.

Table 2. Number and percentage of FY 1987–2006 tort claim cases classified by type of injury

Injury Class Number Percent

Permanent physical

566

39.2%

Death

421

29.2%

Temporary physical

373

25.8%

Non-physical

53

3.7%

Undetermined

28

1.9%

Wrongful birth

3

0.2%

Now that we have seen what types of circumstances commonly led to tort claim allegations of medical malpractice in the IHS/Tribal health care system, let's look at where these incidents tended to occur.

Patient Care Area.  Table 3 shows the number and percentage of cases coded by the patient care area where the predominance of care was provided. A little more than one-third of cases involved primarily inpatient care, while the remaining two-thirds involved care primarily rendered in an outpatient clinic settling (56%) or an emergency room setting (11%). The “other” category refers to cases involving care primarily in the field, such as emergency medical services at the scene of an accident, or home health care; less than 1% of cases fell into this category.

Table 3. Number and percentage of FY 1987-2006 tort claim cases classified by patient care area

Patient Care Area Number Percent

Outpatient

750

51.9%

Inpatient

522

36.1%

Emergency room

159

11.0%

Other

13

0.9%

Facility Type. Within the IHS and tribal network of health care facilities, there are 304 “health centers” that provide only ambulatory services and there are 46 “hospital-based” facilities that provide both inpatient and outpatient services. For the purposes of this analysis the 46 hospital-based facilities were further divided into two groups: “limited service” and “extended service” hospital-based facilities. The limited-service hospital designation refers to the smaller, more remote inpatient facilities with limited obstetrical care, no inpatient surgery, and no intensive care unit. The full-service hospital designation refers to facilities that provide surgical obstetrical deliveries, inpatient general surgery, intensive care, and a few that have additional specialty services such as orthopedics, ophthalmology, otorhinolaryngology, etc.

Table 4 shows the number and percentage of tort claim cases for the three categories of health care facilities common to the IHS and tribal health care systems. Two hundred and eleven cases involved care at health centers, accounting for 14.6% of the total cases. These cases were spread out over 92 different facilities; the average number of cases per facility over the 20-year period was only 2–3 cases per facility, with a range of 1 to 14. Those ambulatory facilities involved with a higher number of cases tended to be larger health centers that offered extended hours with emergency room services. Generally, the prevalence of tort claims is low at IHS- or tribally-operated health centers.

Hospital-based facilities accounted for remaining 1,233 cases, or 85.4% of the total cases. These cases included all the inpatient care cases, most of the emergency room cases, as well as a majority of the outpatient care cases. Incidents at limited-service, hospital-based programs accounted for 315 cases (22% of the total) spread out over 28 facilities. The range of cases per facility was from 1 to 59, with an average of 11–12 cases per facility for the 20-year period. Extended-service, hospital-based facilities accounted for the remaining 918 cases (64% of the total) spread over 16 facilities. The range of cases per facility was from 18 to 114 for the 20-year period, with an average of 57–58 cases per facility. In general, the larger the facility and the more services offered, the higher the prevalence of tort claims.

Table 4. Number and percentage of FY 1987–2006 tort claim cases classified by facility type (see text for definitions)

Facility Type Total Cases Percent of Total No. of Facilities Avg. No. Cases per Facility

Ambulatory Health Center

211

14.6%

92

2.3

Limited-service Hospital-based

315

21.8%

28

11.25

Extended-service Hospital-based

918

63.5%

16

57.4

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