MLMIC Insight: Leading Factors that Contribute to Claims in Healthcare

The use of analytics in healthcare continues to provide insight into the factors that contribute to claims in healthcare. The MPL Association recently reported findings that show allegations related to procedures were identified in 48% of its closed claims from 2016-2018. Major contributing factors were noted to be:

  • incomplete/inadequate procedure;
  • failure to recognize complication(s);
  • procedure not performed when indicated;
  • wrong procedure;
  • procedure not indicated or contraindicated;
  • delay in performance;
  • wrong site; and
  • retained surgical instrument.

Other leading causes of claims were found to be related to diagnosis (33%), medication/iv fluids (7%) and administrative-related issues (4%).

MLMIC’s report on Million Dollar Claims had similar findings. Closed claims (459) from 2013 to 2017 resulting in an indemnity payment of one million dollars or more were reviewed. Allegations of improper performance were identified in 42% or 2 of every 5 files involving a surgical procedure. Our in-depth analysis demonstrated that improper performance involved multiple specialties, and different types of procedures. Additional findings revealed that improper performance may be alleged when there is:

  • a delay in surgery;  
  • a lack of surgical consultation when indicated;
  • a problem encountered during the operative procedure;
  • an issue with patient management in the PACU; and
  • a concern in the care prior to discharge or during the discharge process.

Improper performance is commonly alleged when a procedure was not performed properly or when the patient’s care expectations were not met. Failures in communication, documentation and follow-up were present in all the cases reviewed.

Surgical claims often involve issues pertaining to the pre-operative, intra-operative, and/or post-operative patient management process. Vulnerabilities in any portion of the surgical process can negatively impact the surgical outcome and the quality of patient care.

MLMIC’s Million Dollar Claims Report and its recommendations can be accessed here.  

Comparably, ECRI and the Institute for Safe Medication Practices’ report, Deep Dive: Strategies for Surgical Patient Safety, analyzed 1,561 adverse surgical events reported from July 2018 to June 2019. These surgical events involved:

  • complications;
  • patient and OR readiness;
  • retained surgical items;
  • contamination;
  • equipment failure; and
  • wrong surgery.

A summary of ECRI’s recommendations to minimize risks throughout the surgical process can be found in their Executive Brief.

The following resources are available to assist our policyholders in addressing any concerns they may have related to the issues identified in the three reports: