Small Claims Court Forms Download England

Apr 30, 2015. Taking a case to court can be complicated and is not always appropriate. Find out what's involved if you decide to take court action. Starting a court claim against a trader by issuing your claim online or on paper, and corresponding with the court by e-mail. Pausing your claim is free if you're using the small claims court. If discussions. You can download one from the HMCTS website at www.justice.gov.uk or you can get the form from your local court.

Results Approximately 1% of all physicians accounted for 32% of paid claims. Among physicians with paid claims, 84% incurred only one during the study period (accounting for 68% of all paid claims), 16% had at least two paid claims (accounting for 32% of the claims), and 4% had at least three paid claims (accounting for 12% of the claims). In adjusted analyses, the risk of recurrence increased with the number of previous paid claims. For example, as compared with physicians who had one previous paid claim, the 2160 physicians who had three paid claims had three times the risk of incurring another (hazard ratio, 3.11; 95% confidence interval [CI], 2.84 to 3.41); this corresponded in absolute terms to a 24% chance (95% CI, 22 to 26) of another paid claim within 2 years. Risks of recurrence also varied widely according to specialty — for example, the risk among neurosurgeons was four times as great as the risk among psychiatrists. Figure 2 Probability of Recurrent Paid Claims over Time.

Curves were adjusted for the number of previous paid claims that the physician had had during the study period; the payment year; the physician’s qualification (doctor of medicine vs. Doctor of osteopathic medicine), specialty, age, sex, trainee status (resident vs. Nonresident), practice location (state and rurality), and medical school location (United States vs. Other); and the number of paid claims per 1000 physicians, according to year and specialty.

There are long-standing concerns about claim-prone and complaint-prone physicians. Many studies have compared physicians who have multiple claims against them with colleagues who have few or no claims against them and have identified systematic differences in their age, sex, specialty, training and certification, claim and complaint histories, and quality of care.

However, only a few published studies have analyzed the nature of the maldistribution itself; these studies generally have been limited to claims data from a single insurer or state and date back to the 1970s and 1980s. If claim-prone physicians account for a substantial share of all claims, the ability to reliably identify them before they accumulate troubling track records would be valuable. Attempts to predict malpractice claims have had mixed success and suggest that prospective identification is not feasible. This helps to explain why the medical malpractice system remains largely a reactive enterprise, focused on the aftermath of care that has gone wrong. The chief contribution of the system to the prevention of harm lies in its intended role as a deterrent to substandard care — a function that evidence suggests it performs poorly.

We sought to characterize the distribution of paid malpractice claims among physicians nationwide and physician characteristics associated with incurring multiple paid claims. We expected to find high concentrations of claims. Drawing on methods that were recently developed to analyze patient complaints in Australia, we also anticipated that it would be feasible to identify factors associated with recurrent claims at the physician level. Data and Variables The National Practitioner Data Bank (NPDB) is a confidential data repository created by Congress in 1986 to improve health care quality.

We obtained information on all payments reported to the NPDB against doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s) in the United States between January 1, 2005, and December 31, 2014. We also obtained data on the total number of active physicians in the United States — according to specialty and year — from the American Medical Association (AMA) Physician Masterfile. Most of the study variables were available in the NPDB public-use data file.

We obtained several additional variables (e.g., physician specialty and sex and payment year and month) by special application to the Health Resources and Services Administration (HRSA). Further details regarding the data sources and variables are provided in the, available with the full text of this article at NEJM.org.

Study Data Set Every practitioner who is the subject of an NDPB report is assigned a unique identifier. This identifier allowed us to link multiple reports against the same physician. HRSA checks for and eliminates duplicate reports, except that payment contributions from patient-compensation funds (in the states that have them) are logged as separate reports. We included the state-fund payments in calculations of mean and median payment levels but excluded them from all other analyses, to ensure that each report in our sample related to a separate claim. We excluded paid claims against physicians 65 years of age or older because retirement was a rival explanation for the absence of further paid claims against those physicians. In addition, when a physician had multiple paid claims in the same month, we considered only one, chosen at random, and excluded any others (1959 claims were excluded).

The rationale for these exclusions was related to the multivariable analysis and is described in the. Distributional Analysis We calculated the cumulative distribution of paid claims in two populations of physicians: those with one or more paid claims during the study period and all active physicians in the United States. The count used for the second population was the AMA estimate of the number of active physicians at the median time point in our study period. We tested the sensitivity of our results to this denominator by recalculating the distributional statistics using AMA counts for 2005 and 2014 — the years with the lowest and the highest number of active physicians, respectively; there was virtually no difference in the results.

Additional information on the method used to count physicians according to specialty is available in the. Analysis of Recurrent Claims We used multivariable survival analysis to identify characteristics of physicians at risk for recurrent paid claims.

Specifically, we used an Anderson–Gill model, which allowed each physician in the sample to accrue multiple claims over the study period. The underlying distribution for time was modeled with the use of a flexible parametric survival model. Time at risk was defined as the time from the physician’s first paid claim to the month of the physician’s 65th birthday or to the end of the study, whichever came first. The analysis was at the claim level.

The outcome variable in the model was a paid claim against a physician, conditional on the physician having had an earlier paid claim during the study period. The covariates were the number of previous paid claims that the physician had had during the study period, the payment year, and the physician’s qualification (M.D.

D.O.), specialty, age, sex, trainee status (resident vs. Nonresident), practice location (state and rurality ), and medical school location (United States vs.

In addition, we adjusted for the physician’s exposure to the specialty-specific risk of a claim by including a variable indicating the incidence of paid claims per 1000 physicians in each specialty and year. We calculated cluster-adjusted robust standard errors to account for correlations among physicians who had multiple claims over time. The number of previous paid claims was specified as a time-varying covariate.

Age, trainee status, and practice location were also time-varying in the sense that we allowed physicians to move into different categories of these variables, commensurate with their profile at the time of a payment. To test the robustness of our estimates, we reran the multivariate analysis within specialties and specialty groups.

Finally, to estimate physicians’ absolute risks of having paid claims over time, we plotted adjusted failure curves (1 minus the survivor function). Values for these curves were computed with the use of coefficients from the main multivariable model.

Further details of the modeling approach, the stratified analyses according to specialty, and the technique used to plot the failure curves are provided in the. All analyses were performed with the use of Stata software, version 13.1 (StataCorp).

Sample Characteristics The study sample consisted of 66,426 paid claims against 54,099 physicians. A total of 82% of the physicians were men ( Table 1 Characteristics of Physicians with One or More Paid Malpractice Claims, 2005–2014. More than half the claims were accounted for by physicians in four specialty groups — internal medicine (15%), obstetrics and gynecology (13%), general surgery (12%), and general practice or family medicine (11%). A total of 92% of the physicians were M.D.s, 87% practiced in metropolitan areas, and 77% were trained in the United States. Almost one third of the claims related to patient deaths, and 54% related to “major” or “significant” physical injury defined according to the scale developed by the National Association of Insurance Commissioners (see Table S1 in the ). Only 3% of the claims were paid to satisfy court verdicts for the plaintiff; the rest were out-of-court settlements.

The mean payment amount was $371,054, and the median was $204,750 (in 2014 dollars). Distribution of Claims When the analysis was performed with all 915,564 active physicians in the United States as a denominator, the distribution of paid claims over the 10-year study period was extremely concentrated. Only 6% of physicians had a paid claim. Approximately 1% of physicians (those with ≥2 paid claims) accounted for 32% of all paid claims, and 0.2% of physicians (those with ≥3 paid claims) accounted for 12% of all paid claims. Restricting the background population to physicians with at least one paid claim resulted in a more moderate concentration.

A total of 84% of these physicians had only one paid claim over the study period; they accounted for 68% of all claims. However, 16% of physicians with at least one paid claim (8846 physicians) had at least two paid claims and accounted for 32% of all claims, 4% of them (2160 physicians) had at least three paid claims and accounted for 12% of all claims, and 1% of them (722 physicians) had at least four paid claims and accounted for 5% of all claims ( Figure 1 Number of Paid Claims Accumulated by Physicians.

Factors Associated with Recurrent Claims In multivariable analysis, physicians’ risk of future paid claims increased monotonically with their number of previous paid claims ( Table 2 Variables Associated with Recurrent Paid Malpractice Claims among Physicians with One or More Paid Claims. As compared with physicians who had one previous paid claim, physicians who had two paid claims had almost twice the risk of having another one (hazard ratio, 1.97; 95% confidence interval [CI], 1.86 to 2.07), physicians with three paid claims had three times the risk of recurrence (hazard ratio, 3.11; 95% CI, 2.84 to 3.41), and physicians with six or more paid claims had more than 12 times the risk of recurrence (hazard ratio, 12.39; 95% CI, 8.69 to 17.65).

Repeating the multivariable analyses within specialties and specialty groups produced similar estimates of the effect of previous paid claims on the risk of recurrence (see Table S2 in the ). Risks also varied widely according to specialty.

As compared with the risk of recurrence among internal medicine physicians, the risk of recurrence was approximately double among neurosurgeons (hazard ratio, 2.32; 95% CI, 1.77 to 3.03), orthopedic surgeons (hazard ratio, 2.02; 95% CI, 1.70 to 2.40), general surgeons (hazard ratio, 2.01; 95% CI, 1.65 to 2.46), plastic surgeons (hazard ratio, 1.95; 95% CI, 1.60 to 2.37), and obstetrician–gynecologists (hazard ratio, 1.89; 95% CI, 1.58 to 2.25) ( ). The lowest risks of recurrence were seen among psychiatrists (hazard ratio, 0.60; 95% CI, 0.43 to 0.82) and pediatricians (hazard ratio, 0.71; 95% CI, 0.59 to 0.85). Male physicians had a 38% higher risk of recurrence than female physicians (hazard ratio, 1.38; 95% CI, 1.30 to 1.46). The risk of recurrence among physicians younger than 35 years of age was approximately one third the risk among their older colleagues.

Residents had a lower risk of recurrence than nonresidents, and M.D.s had a lower risk than D.O.s. Risks of Recurrence over Time Figure 2 Probability of Recurrent Paid Claims over Time. Curves were adjusted for the number of previous paid claims that the physician had had during the study period; the payment year; the physician’s qualification (doctor of medicine vs. Doctor of osteopathic medicine), specialty, age, sex, trainee status (resident vs. Nonresident), practice location (state and rurality), and medical school location (United States vs. Other); and the number of paid claims per 1000 physicians, according to year and specialty.

Shows the cumulative risk of recurrent paid claims over a 5-year period, according to the number of paid claims that a physician had already accumulated during the study period. The 2160 physicians who reached a third paid claim had a 24% chance (95% CI, 22 to 26) of another paid claim within 2 years and a 37% chance (95% CI, 35 to 40) of another within 4 years. The 126 physicians who reached a sixth paid claim had a 62% chance (95% CI, 51 to 74) of another within 2 years and a 79% chance (95% CI, 69 to 88) of another within 4 years. The steep rise and plateauing of the failure curves for physicians with three or more previous paid claims indicate that physicians’ instantaneous risk of incurring additional claims was highest in the year after a payment was made and declined gradually thereafter. Shows the risk of recurrent paid claims over a 5-year period for physicians in six specialties. The range of risk across the specialties is substantial.

For example, psychiatrists with one or more paid claims had a 5% chance (95% CI, 3 to 6) of incurring another within 2 years and an 8% chance (95% CI, 5 to 10) of incurring another within 4 years. By contrast, neurosurgeons with one or more paid claims had a 16% chance (95% CI, 13 to 19) of incurring another within 2 years and a 26% chance (95% CI, 22 to 30) of incurring another within 4 years.

Discussion This study showed that over a recent 10-year period, a relatively small group of U.S. Physicians accounted for a disproportionately large share of paid malpractice claims. Several physician characteristics, most notably the number of previous claims and the physician’s specialty, were significantly associated with recurrence of claims. For example, the 2160 physicians in our sample who incurred their third paid claim had high risks of recurrence, in both relative terms (>3 times as high as physicians with one paid claim) and absolute terms (24% risk of recurrence within 2 years). The claim concentrations that we estimated are larger than those previously reported.

In part, this may be a function of our study window, which allowed claims to accrue over a longer period than most previous studies have. Concentrations detectable in single-insurer analyses may also be lower if physicians with multiple claims switched insurers or had their coverage terminated, because future claims against those physicians would not have been observed. (For the same reason, a liability insurer may not absorb the full costs of claim-prone physicians.) Another explanation for the high concentrations that we found is claim mix: most previous studies have analyzed all claims, and paid claims may be more concentrated than unpaid ones. Finally, with the exception of a 2007 report by Public Citizen, distributional statistics reported in the literature to date relate to litigation from more than 25 years ago, and the concentration of claims among physicians may have increased since then.

It is important to recognize that claim concentrations over a given period of time are a function of two factors: an individual physician’s propensity to attract claims and the baseline incidence of claims in the population. Our analysis focused on the former and sought to adjust for the latter, but the two phenomena are difficult to disentangle. Specialty is a particularly strong determinant of claim incidence.

The consistency of our main results in within-specialty analyses was therefore reassuring. Some of the physician characteristics associated with future claims that we identified — particularly, specialty, sex, and age — were detected in earlier claims-prediction studies. However, the modeling approach that we used enhanced our ability to identify risk factors for recurrent claims. The approach developed by Rolph et al. And emulated by others relies on a snapshot of physicians’ event histories at a particular moment in time. Recurrent-event survival analysis permits dynamic consideration of time-varying factors that may predict claims.

As physicians’ risk profiles evolve, those changes can be incorporated into estimations of future risk. A related advantage of survival analysis is that it permits estimation of physicians’ risk levels at future time points. The failure curves that we estimated suggest that the instantaneous risk of further paid claims was highest soon after a payment was made and then leveled off after a few years. Temporal clustering of claims warrants further examination. Our study has several limitations. First, some malpractice payments do not reach the NPDB.

The extent of underreporting is unknown; however, the most serious concerns about underreporting center on physicians whose names are “shielded” through settlements made in the name of an institutional codefendant. Shielding is most likely in settings in which physicians and hospitals are covered by the same liability insurer, the delivery system is tightly integrated, or physicians exert substantial control. To the extent that claims were underreported, we will have underestimated the number of physicians who have multiple claims.

The effects on the proportion of all physicians with multiple claims and the estimates from the multivariable model are unknown; they depend on how underreported claims are distributed in the physician population. Second, we used head counts of physicians rather than more sophisticated measures of their exposure to claim risk, such as hours worked, volume of patients treated, or patient case mix. Third, because we observed directly the occurrence of paid claims rather than a cohort of physicians, there will have been some unobserved censoring in our data. Some physicians may have ceased being “at risk” after a first or subsequent paid claim owing to a decision to no longer treat patients, early retirement, or license suspension or revocation. Such unobserved censoring probably biased our results toward underestimation of claim concentrations. Finally, focusing on paid claims has advantages and disadvantages. Although payment does not necessarily indicate that a claim has merit, paid claims are much more likely than unpaid claims to involve substandard care.

On the other hand, approximately 70% of all claims do not result in payments, and these events still vex defendants, are costly to bring and defend, and flag patient dissatisfaction (or worse). Future researchers should consider applying distributional and predictive analyses to both types of claims and to other types of medical–legal events (e.g., disciplinary actions and patient complaints). All institutions that handle large numbers of patient complaints and claims should understand the distribution of these events within their own “at risk” populations. In our experience, few do.

With notable exceptions, fewer still systematically identify and intervene with practitioners who are at high risk for future claims. Rather, the risk-mitigation initiatives that are in place — such as the educational and premium-discount programs that some malpractice-insurance companies offer — are generally offered en masse. Otherwise, insurers tackle the problem of claim-prone physicians primarily by raising premiums or terminating coverage. These strategies do not directly address the underlying problems that lead to many claims. In an environment in which a small minority of physicians with multiple claims accounts for a substantial share of all claims, an ability to reliably predict who is at high risk for further claims could be very useful.

Our analysis suggests, but does not establish, the feasibility of such prediction. If reliable prediction proves to be feasible, our hope is that liability insurers and health care organizations would use the information constructively, by collaborating on interventions to address risks posed by claim-prone physicians (e.g., peer counseling, training, and supervision). It could present an exciting opportunity for the liability and risk-management enterprises to join the mainstream of efforts to improve quality.

Adobe Flash Player is required to view this feature. If you are using an operating system that does not support Flash, we are working to bring you alternative formats. Special Article Claims, Errors, and Compensation Payments in Medical Malpractice Litigation David M.

Studdert, LL.B., Sc.D., M.P.H., Michelle M. Mello, J.D., Ph.D., M.Phil., Atul A.

Gawande, M.D., M.P.H., Tejal K. Gandhi, M.D., M.P.H., Allen Kachalia, M.D., J.D., Catherine Yoon, M.S., Ann Louise Puopolo, B.S.N., R.N., and Troyen A. Brennan, M.D., J.D., M.P.H. N Engl J Med 2006; 354:2024-2033 DOI: 10.1056/NEJMsa054479.

Results For 3 percent of the claims, there were no verifiable medical injuries, and 37 percent did not involve errors. Most of the claims that were not associated with errors (370 of 515 [72 percent]) or injuries (31 of 37 [84 percent]) did not result in compensation; most that involved injuries due to error did (653 of 889 [73 percent]). Payment of claims not involving errors occurred less frequently than did the converse form of inaccuracy — nonpayment of claims associated with errors. When claims not involving errors were compensated, payments were significantly lower on average than were payments for claims involving errors ($313,205 vs. $521,560, P=0.004). Overall, claims not involving errors accounted for 13 to 16 percent of the system's total monetary costs.

For every dollar spent on compensation, 54 cents went to administrative expenses (including those involving lawyers, experts, and courts). Claims involving errors accounted for 78 percent of total administrative costs. The debate over medical malpractice litigation continues unabated in the United States and other countries. Advocates of tort reform, including members of the Bush administration, lament the burden of “frivolous” malpractice lawsuits and cite them as a driving force behind rising health care costs. (A frivolous claim is one that “present[s] no rational argument based upon the evidence or law in support of the claim.” ) Plaintiffs' attorneys refute this charge, countering that contingency fees and the prevalence of medical errors make the pursuit of meritless lawsuits bad business and unnecessary. Previous research has established that the great majority of patients who sustain a medical injury as a result of negligence do not sue.

However, the merit of claims that are brought, and the ability of the malpractice system to resolve them appropriately, remain much more controversial. If frivolous claims are common and costly, they may be a substantial source of waste in the health care and legal systems.

We investigated the merits and outcomes of malpractice litigation using structured retrospective reviews of 1452 closed claims. The reviews included independent assessments of whether the claim involved injury due to medical error. Our aim was to measure the prevalence, costs, outcomes, and distinguishing characteristics of claims that did not involve identifiable error. Claims Sample Data were extracted from random samples of closed-claim files at each insurance company. The claim file is the repository of information accumulated by the insurer during the life of a claim (see the, available with the full text of this article at www.nejm.org). We also obtained the relevant medical records from insured institutions for all claims included in the sample. Following the methods used in previous studies, we defined a claim as a written demand for compensation for medical injury.

Anticipated claims or queries that fell short of actual demands did not qualify. We focused on four clinical categories — obstetrics, surgery, missed or delayed diagnosis, and medication — and applied a uniform definition of each at all sites. These are key clinical areas of concern in research on patient safety; they are also areas of paramount importance to risk managers and liability insurers, accounting for approximately 80 percent of all claims in the United States and an even larger proportion of total indemnity costs. Insurers contributed claims to the study sample in proportion to their annual volume of claims.

The number of claims by site varied from 84 to 662 (median, 294). One site contributed obstetrics claims only; another site had claims in all categories except obstetrics; and the remaining three contributed claims from all four categories.

Review of Claim Files Reviews were conducted at insurers' offices or insured facilities by board-certified physicians, fellows, or final-year residents in surgery (for surgery claims), obstetrics (for obstetrics claims), and internal medicine (for diagnosis and medication claims). Physician investigators from the relevant specialties trained the reviewers, in one-day sessions at each site, with regard to the content of claims files, use of the study instruments, and confidentiality procedures. Reviewers were also given a detailed manual. Reviews lasted 1.6 hours per file on average and were conducted by one reviewer.

To test the reliability of the process, 10 percent of the files were reviewed again by a second reviewer who was unaware of the first review. Staff members at the insurance companies recorded administrative details of each claim, and clinical reviewers recorded details of the patient's adverse outcome, if any. Physician reviewers then scored adverse outcomes on a severity scale that ranged from emotional injury to death. If there was no identifiable adverse outcome, the review was terminated. For all other claims, reviewers considered the potential contributory role of 17 “human factors” in causing the adverse outcome. Next, in the light of all available information and their decisions about contributing factors, reviewers judged whether the adverse outcome was due to medical error.

We used the definition of error of the Institute of Medicine: “the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).” Reviewers recorded their judgments using a 6-point confidence scale in which a score of 1 indicated little or no evidence that an adverse outcome resulted from one or more errors and a score of 6 indicated virtually certain evidence that an adverse outcome resulted from one or more errors. Claims that received a score of 4 (“more likely than not that adverse outcome resulted from error or errors; more than 50–50 but a close call”) or higher were classified as involving an error. Reviewers were not blinded to the outcome of litigation because it was logistically impossible to censor this information in the files.

However, they were instructed to ignore this outcome and exercise independent clinical judgment in rendering determinations with regard to injury and error. Training sessions stressed both that the study definition of error is not synonymous with the legal definition of negligence and that a mix of factors extrinsic to merit influences whether claims are paid during litigation. Statistical Analysis The data forms, which had been filled out by hand, were electronically entered into a database and verified by a professional data-entry vendor and then sent to the Harvard School of Public Health in Boston for analysis.

Analyses were conducted with the use of the SAS 8.2 and Stata SE 8.0 statistical software packages. To compare characteristics of claims with and claims without errors, we used Fisher's exact tests (for analyses involving the sex of the plaintiff, specialty of the defendant, severity of injury, type of claim, and litigation outcomes), t-tests (for analyses involving the age of the plaintiff and filing and closure periods), and Wilcoxon rank-sum tests (for analyses involving indemnity and defense costs).

All reported P values are two-sided. The total cost of claims in the sample was calculated and apportioned between claims with and those without errors. The analysis addressed the direct costs of the litigation, not the indirect costs, such as those associated with the practice of defensive medicine. We refer to the patient who allegedly sustained injury as the plaintiff, even though some claims were brought by third parties. We used kappa scores to measure the reliability of the determinations of injury and error.

Characteristics of the Plaintiffs Sixty percent of the plaintiffs were female ( Table 1 Characteristics of Litigants, Injuries, and 1452 Claims. The median age of the plaintiffs was 38 years; 19 percent were newborns, and 12 percent were 65 years of age or older.

Obstetrician-gynecologists were the most frequently sued physicians in the sample (19 percent), followed by general surgeons (17 percent) and primary care physicians (16 percent). In 37 of the claims (3 percent), no adverse outcome from medical care was evident. For example, one claim alleged that substandard care had caused the plaintiff to acquire methicillin-resistant Staphylococcus aureus, but there was no evidence of infection in the medical record or claim file. An additional 52 claims (4 percent) involved psychological or emotional injury, and 9 (.

Shirdi Ke Sai Baba Movie Songs Downloadming on this page. Relationship between Error and Compensation Sixty-three percent of the injuries were judged to be the result of error ( Figure 1 Overview of the Relationship among Claims, Injuries, Errors, and Outcomes of Litigation. For claims classified as involving dignitary injury only, a breach of informed consent was the only injury alleged in the claim. Five of these claims resulted in payment.

Most claims involving injuries due to error received compensation (653 of 889 [73 percent]), and most claims that did not involve errors (370 of 515 [72 percent]) or injuries (31 of 37 [84 percent]) did not. Overall, 73 percent (1054 of 1441) of all claims for which determinations of merit were made had outcomes concordant with their merit.

Discordant outcomes in the remaining 27 percent of claims consisted of three types: payment in the absence of documented injury (6 of 1441 [0.4 percent of all claims]), payment in the absence of error (10 percent), and no payment in the presence of error (16 percent). Thus, nonpayment of claims with merit occurred more frequently than did payment of claims that were not associated with errors or injuries. All results hereafter relate to the subsample of 1404 claims that involved injuries and for which determinations of error were made.

Confidence in Judgments Regarding Error Reviewers had a high level of confidence in the determination of error in 44 percent of claims (those receiving scores of 1 or 6) and a moderate level of confidence in 30 percent (those receiving scores of 2 or 5); the remaining 23 percent were deemed “close calls” ( Figure 2 Determinations of Error According to Confidence Level and Payment Status. The 1404 claims exclude the 9 that were associated with dignitary injuries only, the 37 with no injuries, and the 2 for which no judgments regarding error were made. More than half the claims that were classified as not involving error had little or no evidence of error. The probability of payment increased monotonically with reviewers' confidence that an error had occurred. Characteristics of Claims Not Involving Error With respect to characteristics of the litigant, severity of the injury, and type of claim, there were few differences between claims that did not involve error and those that did ( Table 2 Characteristics of Claims Involving Error and Those Not Involving Error. However, the outcomes of litigation among claims not associated with error (non-error claims) and those associated with error (error claims) differed significantly. Non-error claims were more likely to reach trial than were error claims (23 percent vs.

10 percent, P. Total Expenditures The claims in the study sample cost more than $449 million, with total indemnity costs of more than $376 million and defense costs of almost $73 million ( Table 3 Apportionment of Total Expenditures between Claims Involving Error and Those Not Involving Error.

Non-error claims accounted for 16 percent of total system costs, 12 percent of indemnity costs, and 21 percent of administrative costs. With the exclusion of the 85 claims in which the reviewers' judgment that the claim did not involve error was a close call, non-error claims accounted for 13 percent of total expenditures.

Reliability and Sensitivity Analyses Reliability testing was performed on the basis of 148 pairs of reviews. Kappa scores were 0.78 (95 percent confidence interval, 0.65 to 0.90) for the determination of injury and 0.63 (95 percent confidence interval, 0.12 to 0.74) for the judgment that error occurred, but scores for the latter varied across the clinical categories (surgery, 0.80; medication, 0.76; obstetrics, 0.56; and diagnosis, 0.42). The exclusion of claims in which the primary reviewer classified the determination of error as a close call substantially boosted the overall reliability (kappa score, 0.80; 95 percent confidence interval, 0.32 to 0.88) and category-specific reliability (surgery, 0.94; medication, 0.90; obstetrics, 0.67; diagnosis, 0.63) of the error judgments. In this smaller sample of claims, the proportion that did not involve error increased slightly, to 40 percent (430 of 1065), and changes with regard to the magnitude and significance of the various differences between the two types of claims (as shown in ) were trivial. Our main findings were also robust when a sensitivity analysis was performed that excluded the obstetrics claims and diagnosis claims, the two clinical categories with the lowest levels of reliability. Discussion We found that only a small fraction of claims lacked documented injuries.

However, approximately one third of claims were without merit in the sense that the alleged adverse outcomes were not attributable to error. Claims without merit were generally resolved appropriately: only one in four resulted in payment. When close calls were excluded, claims without evidence of injury or error accounted for 13 percent of total litigation costs. Several previous studies have investigated the relationship between the merits and outcomes of malpractice claims.

The findings vary widely, with 40 to 80 percent of claims judged to lack merit and 16 to 59 percent of claims without merit receiving payment. Each of the studies also has important weaknesses: they involved the use of small numbers of claims; they focused on a single hospital, insurer, specialty, or type of injury; they involved the use of very limited information in the determination of merit; or they relied on the insurer's view of the defensibility of the claim as a proxy for merit rather than on independent expert judgments.

Our study was designed to avoid these limitations. Cheney and colleagues analyzed 1004 claims involving the use of anesthesia that were closed at 17 insurers in the 1970s and 1980s and found that approximately 40 percent of the claims did not involve substandard care, of which 42 percent received payment. We detected a similar proportion of claims that did not involve error, but much fewer of them resulted in compensation. We found stark differences in the outcomes of litigation for claims that did and those that did not involve errors: non-error claims were more than twice as likely as error claims to go to trial; they were nearly one third as likely to result in compensation; and when the plaintiffs received compensation, payments averaged 60 percent of the amount paid for error claims. Otherwise, non-error claims had few distinguishing characteristics. Economic theories regarding litigants' behavior suggest that two characteristics will mark such claims: close calls in terms of whether an error has occurred and relatively serious injury. Neither characteristic was borne out in our analyses.

The profile of non-error claims we observed does not square with the notion of opportunistic trial lawyers pursuing questionable lawsuits in circumstances in which their chances of winning are reasonable and prospective returns in the event of a win are high. Rather, our findings underscore how difficult it may be for plaintiffs and their attorneys to discern what has happened before the initiation of a claim and the acquisition of knowledge that comes from the investigations, consultation with experts, and sharing of information that litigation triggers. Previous research has described tort litigation as a process in which information is cumulatively acquired. Our findings point toward two general conclusions. One is that portraits of a malpractice system that is stricken with frivolous litigation are overblown.

Although one third of the claims we examined did not involve errors, most of these went unpaid. The costs of defending against them were not trivial.

Nevertheless, eliminating the claims that did not involve errors would have decreased the direct system costs by no more than 13 percent (excluding close calls) to 16 percent (including close calls). In other words, disputing and paying for errors account for the lion's share of malpractice costs. A second conclusion is that the malpractice system performs reasonably well in its function of separating claims without merit from those with merit and compensating the latter.

In a sense, our findings lend support to this view: three quarters of the litigation outcomes were concordant with the merits of the claim. However, both of these general conclusions obscure several troubling aspects of the system's performance. Although the number of claims without merit that resulted in compensation was fairly small, the converse form of inaccuracy — claims associated with error and injury that did not result in compensation — was substantially more common. One in six claims involved errors and received no payment. The plaintiffs behind such unrequited claims must shoulder the substantial economic and noneconomic burdens that flow from preventable injury.

Moreover, failure to pay claims involving error adds to a larger phenomenon of underpayment generated by the vast number of negligent injuries that never surface as claims. In addition, enthusiasm about the precision of the malpractice system must be tempered by recognition of its costs. Among the claims we examined, the average time between injury and resolution was five years, and one in three claims took six years or more to resolve. These are long periods for plaintiffs to await decisions about compensation and for defendants to endure the uncertainty, acrimony, and time away from patient care that litigation entails. In monetary terms, the system's overhead costs are exorbitant.

The combination of defense costs and standard contingency fees charged by plaintiffs' attorneys (35 percent of the indemnity payment) brought the total costs of litigating the claims in our sample to 54 percent of the compensation paid to plaintiffs. The fact that nearly 80 percent of these administrative expenses were absorbed in the resolution of claims that involved harmful errors suggests that moves to combat frivolous litigation will have a limited effect on total costs. Substantial savings depend on reforms that improve the system's efficiency in the handling of reasonable claims for compensation. Our study has four main limitations.

First, the sample was drawn from insurers and involved clinical categories that are not representative of malpractice claims nationwide. Academic institutions and the physicians who staff them were overrepresented, as were claims that fell within our clinical categories of interest. Although it is difficult to make comparisons with other samples of closed claims, both the proportion of claims receiving payments and the average amount of the payments appear to be high according to national standards, which probably reflects the preponderance of severe injuries in our sample. Second, the reliability of judgments that error had occurred was moderate overall; agreement was especially difficult to obtain among claims involving missed or delayed diagnoses. Download Software Solidworks 2005 there. Third, whether claims had merit was determined by reference to error, which is not identical to the legal concept of negligence, although the two cleave so closely that experts in both medicine and law have trouble explaining the difference. Fourth, reviewers' awareness of the litigation outcome may have biased them toward finding errors in claims that resulted in compensation, and vice versa. To the extent that such hindsight bias was a factor, its likely effect would be to pull the rate of non-error claims (37 percent) toward the payment rate (56 percent), resulting in an overestimate of the prevalence and costs of claims not associated with error.

Frivolous litigation is in the bull's-eye of the current tort-reform efforts of state and federal legislators. The need to constrain the number and costs of frivolous lawsuits is touted as one of the primary justifications for such popular reforms as limits on attorneys' fees, caps on damages, panels for screening claims, and expert precertification requirements. Our findings suggest that moves to curb frivolous litigation, if successful, will have a relatively limited effect on the caseload and costs of litigation.

The vast majority of resources go toward resolving and paying claims that involve errors. A higher-value target for reform than discouraging claims that do not belong in the system would be streamlining the processing of claims that do belong. Supported by grants from the Agency for Healthcare Research and Quality (HS011886-03 and KO2HS11285, to Dr.

Studdert), and the Harvard Risk Management Foundation. No potential conflict of interest relevant to this article was reported. We are indebted to Allison Nagy for her assistance in compiling the data set; to Karen Lifford, Tom McElrath, and Martin November for their assistance with the obstetric component of the study; to Selwyn Rogers for his assistance with the surgical component; to Eric Thomas and Eric Poon for their assistance with the medication and diagnostic components; and to John Ayanian, Arnold Epstein, John Orav, and Charles Silver for their valuable comments on an earlier draft of the manuscript. References • 1 Studdert DM, Mello MM, Brennan TA. Medical malpractice. N Engl J Med 2004;350:283-292 • 2 Chief Medical Officer, National Health Service. Making amends: a consultation paper setting out proposals for reforming the approach to clinical negligence in the NHS.

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