Malpractice claim numbers similar for inpatient and outpatient settings

More than half of all malpractice claims involve outpatient care, although inpatient claims are more expensive on average, a study found.

To report and compare the number, magnitude, and type of paid malpractice claims for each setting, researchers conducted a retrospective analysis of malpractice claims recorded by the National Practitioner Data Bank from 2005 through 2009. Results appeared in the June 15 Journal of the American Medical Association.

Researchers evaluated claims paid by setting, characteristics of paid claims, and factors associated with payment amount. In 2009, 10,739 malpractice claims were paid. Of these payments, 4,910 (47.6%) were for inpatient events and 4,448 (43.1%) were for outpatient events. Another 966 (9.4%) involved events in both settings.

While the overall number of malpractice claims decreased significantly from 2005 to 2009 in all three categories, inpatient claims declined the most. Inpatient claims declined from 6,515 in 2005 to 4,910 in 2009 while outpatient claims declined from 5,511 in 2005 to 4,448 in 2009 (P<0.001). The proportion of payments that were made for events in the outpatient setting increased a small but significant amount, from 41.7% in 2005 to 43.1% in 2009 (P<0.001).

For inpatient care, the events that led to the claims were most commonly surgical (34.1%), diagnostic (21.1%) and treatment (20.3%). In the outpatient setting, the most common were diagnostic (45.9%), treatment (29.5%) and surgical (14.4%). Major injury was the most common outcome in the inpatient (37.8%) and outpatient (36.1%) settings. Death was the next most common outcome in the inpatient (36.1%) and outpatient (30.6%) settings.

The mean payment amount of $362,965 for inpatient events was significantly higher than the amount of $290,111 for outpatient events (P<0.001), as was the median payment amount (inpatient, $195,000 [interquartile ratio, $77,500-$495,000]; outpatient, $145,000 [interquartile ratio, $47,500-$375,000]; P<0.001). Mean payment amount (in 2009 U.S. dollars) did not increase significantly in either setting (P<0.05 for all settings).

The authors wrote, “Events related to diagnosis may be particularly important in the outpatient setting, where follow-up is more difficult than in the hospital and where patients often present with symptoms and signs that may be subtle or not adequately noted amid the many short-term, long-term, and preventive care activities often undertaken in a single outpatient visit.”

But, they added, improving patient safety is more difficult in the outpatient setting because many practices are too small to have well-trained staff devoted to patient safety.

“Because the amount per claim paid is higher in the inpatient setting and inpatient patient safety efforts may be easier to undertake, it is understandable that efforts to date have focused on inpatient care,” the authors concluded. “However, the high volume of outpatient malpractice claims and the serious nature of many of these claims suggest that the relative neglect of outpatient safety should not persist.”

An accompanying editorial described the situation as good news-bad news. While malpractice claims are decreasing overall, current ambulatory risk management is insufficient. “It is likely that with the continued shift to care delivery in ambulatory settings, the medical home, and the growth of hospital-based ambulatory networks, the risk of malpractice in the ambulatory setting will continue to increase,” the editorial concluded.