Improving patient safety

Abstract

The analysis of closed malpractice claim files is a valid and useful technique for learning from past experience. Harvard and the Risk Management Foundation (RF-HMI) were among the pioneers in this approach and have proven the value of looking beyond medical records to the more comprehensive information available in malpractice claim files. Helpful risk prevention strategies in several clinical disciplines have been the result. In this issue of Neurology , Glick et al.1 add to an expanding literature that describes neurology malpractice claims.2–4 Glick et al. reviewed 42 closed claims under the purview of the RMF-HMI. Of these claims, 24 represented, in the authors’ opinion, “authentic, partially or wholly preventable adverse events.”1 The detail of the reports provides insights unavailable from larger administrative studies that lack such in-depth case analysis. Instances of medical malpractice commonly implicate faulty systems of care rather than individual physicians. Substantial gains in patient safety often result from making systems modifications.5 The Glick et al. analysis of legitimate claims reinforces that idea: medication errors …