September 2006

Grant Results

National Program

Improving Malpractice Prevention and Compensation Systems

SUMMARY

From 1994 to 1997, staff at two organizations worked to develop administrative no-fault malpractice compensation systems in Colorado and Utah and to collect and analyze medical-injury data for the two states. Project staff also examined financial, policy and legal issues critical to the design of a no-fault system.

The organizations were:

  • Copic Insurance Co., a physician-owned professional liability carrier in Colorado.
  • Utah Alliance for Health Care, a nonprofit coalition of Utah health care provider organizations and other interests.

Both of these organizations also worked with a Harvard University academic team — headed by Troyen A. Brennan, M.D., J.D., M.P.H., a physician and lawyer on the Harvard Medical School and Harvard School of Public Health faculties as well as on the staff of Brigham and Women's Hospital, a Harvard teaching affiliate — to oversee the research.

The project was part of the Robert Wood Johnson Foundation's (RWJF) Improving Malpractice Prevention and Compensation Systems national program.

Key Results

  • In both Colorado and Utah, the preparation of an administrative system was not completed, and a no-fault system was never implemented.

Key Findings
Among the findings of the medical-injury study, the Harvard team reported that:

  • The adverse event rate among hospitalized patients in each state in 1992 was an estimated 2.9 percent. (An adverse event was defined as an injury caused by medical management and resulting in either a prolonged hospital stay or disability at time of discharge.)
  • The cost of all adverse events in the two states in 1992 totaled $661.9 million, substantially exceeding the money spent on the current medical malpractice system.
  • The estimated annual cost of a no-fault model could be significantly reduced by restricting compensation to certain "avoidability" and disability criteria.

Funding
RWJF supported this project through five grants totaling $1,726,794:

  • Two grants to Copic Medical Foundation.
  • One grant to Utah Alliance for Healthcare.
  • Two grants to Brigham and Women's Hospital.

 See Grant Detail & Contact Information
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THE PROBLEM

Management of the Colorado-based Copic Insurance Co., a large, physician-owned professional liability carrier in Colorado, considered the tort system both inefficient and unnecessarily expensive in determining reimbursement for patient injury. Copic Insurance, the state's dominant malpractice carrier, and the Copic Medical Foundation, a tax-exempt charitable organization, are subsidiaries of the same holding company, Copic Trust.

As a replacement, the company was interested in developing a statewide no-fault system that would compensate medically injured patients administratively instead of through the courts. Copic envisioned establishment of a quasi-governmental entity that would be the sole remedy for injured patients, much as the state worker's compensation authority is for injured workers. Claims would undergo speedy nonadversarial adjudication, and patients who sustained qualifying disabling injury, or the relatives of those who died, would receive compensation, although the extent of compensation was among many details still undetermined. Under this concept the courts would play only a limited role, on appeal of decisions.

In preparation of an administrative plan for consideration by the Colorado legislature, Copic wanted to gather and analyze data on medical injuries in the state and compare the cost of compensation under no-fault with that of the existing tort system. The company's management believed the legislature would be unwilling to undertake such a radical shift without the benefit of a study exploring the feasibility. However, Copic viewed newly enacted tort reforms as evidence of the legislature's potential receptiveness to change. In addition, the study data were to serve as a baseline for evaluation of the new system once it was in place.

The project director, K. Mason Howard, M.D., was chairman and CEO of all three entities from 1981 to 1995 and a director emeritus from 1995 to 1998.

In Utah, a separate but similar effort was underway. Utah health care provider organizations and other interests formed the Utah Alliance for Health Care to develop a no-fault administrative compensation system for the state. Participants in this nonprofit coalition included the Utah hospital, medical, nurses, and medical insurance associations as well as the state's AFL-CIO and AARP organizations. Salt Lake City lawyer Elliott Williams, outside counsel to the Utah Medical Association and Utah Medical Insurance Association and director of this project, was active in the Alliance effort.

The Alliance developed the outline of a no-fault administrative system that it named EPIC (for Experiment in Patient Injury Compensation). Under EPIC, any hospital patient who believed he or she had sustained a medical injury could seek compensation through a simple application. Each hospital would have a medical panel to determine which injuries were compensable and propose a settlement based on explicit criteria. A patient dissatisfied with the decision could appeal to a state administrative agency and then to the Utah Court of Appeals. Only serious injuries would be covered, but patients who did qualify would be compensated for medical expenses, lost wages, and pain and suffering. EPIC made hospitals entities responsible for paying compensation — a feature (termed enterprise liability) designed to give health care enterprises a strong incentive to ensure high-quality care and address patterns of patient injury.

One difference between the approaches in the two states was that the Alliance planned to test its system at an undetermined number of hospital demonstration sites instead of moving directly to statewide implementation, as Copic hoped to do. But, like Copic, before proceeding further, the Alliance wanted to study a number of issues, including Utah's rate of patient injury, the type and severity of injuries to be eligible for compensation, and the specific nature of the administrative process. Also as in Colorado, the Alliance considered Utah's political climate conducive to such an experiment.

Independently of each other, Copic and the Alliance pursued their plans for a medical-injury study by contacting Troyen A. Brennan, M.D., a physician and lawyer on the Harvard Medical School and Harvard School of Public Health faculties as well as on the staff of Brigham and Women's Hospital, a Harvard teaching affiliate. Brennan was a member of the team that in the early 1990s published the Harvard Medical Practice Study, benchmark research on medical injuries in hospitals in New York State.

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THE PROJECT

These five grants made by RWJF through its IMPACS program supported efforts to develop administrative no-fault malpractice compensation systems in Colorado and Utah and to collect and analyze medical-injury data for the two states. The two no-fault efforts — by Copic in Colorado and the Alliance in Utah — were separate projects. However, the grantees subcontracted with the same Harvard University academic team to oversee the medical-injury study of their states and to assist in investigating financial, policy, and legal questions critical to the design of a no-fault system.

For both projects, the Harvard team's work was a key component. Also, subsequent to the main Copic and Alliance grants, RWJF awarded two IMPACS grants directly to Brigham and Women's Hospital for the Harvard team to do additional work on the Colorado and Utah data (ID#s 029907 and 032865). As a result, although funded and administered independently of each other, the Colorado and Utah projects became closely intertwined and collaborative. For example, the published articles resulting from the research dealt with both states in tandem.

Given the technical complexity and political divisiveness of no-fault, RWJF viewed the two projects as highly risky. But with the relatively favorable political climates of Colorado and Utah and the enthusiasm of the two in-state sponsors, it was considered a risk worth taking.

The first of Copic's two IMPACS grants (ID# 022603) provided funding to:

  1. Collect baseline data on Colorado's medical injury rates and estimate compensation under the existing tort system.
  2. Estimate the cost of a no-fault administrative system and design its financial aspects.
  3. Develop model statutory language to create an administrative system.
  4. Prepare a plan for evaluating the effectiveness of the new system.

In essence, the grant was intended to move no-fault from a concept to a system ready for implementation. However, implementation itself, including enactment of enabling legislation, was not covered by the grant. Copic planned to use its own taxable funds to pay for any lobbying activities undertaken in connection with passage of the implementing law.

In addition to hiring the Harvard team to conduct the bulk of the analysis necessary to meet the objectives enumerated above, Copic's activities included:

  • Contracting with the Colorado Foundation for Medical Care, the state's Medicare/Medicaid peer review organization, to coordinate the review of hospital patient records for the medical-injury study. Reviewers screened approximately 10,000 discharge records from 15 Colorado hospitals.
  • Providing its own claims data for the study and seeking the cooperation of other health care-related entities in the state, including insurers and physician organizations. A commercial malpractice carrier, The Doctors' Co., and two self-insured institutions, Kaiser Permanente and University Hospital in Salt Lake City, also provided claims data, giving the Harvard researchers access to more than 90 percent of the state's physician liability insurance market.
  • Assembling an advisory group to help guide the project. (See Appendix 1 for a list of the members.)
  • Soliciting — unsuccessfully, as it turned out — project funding from other foundations. Copic's own foundation contributed $50,000.
  • Coordinating data gathering in Colorado with Harvard researchers in Boston, assisting in claims analysis, and working on developing the statutory language to create the administrative compensation agency.

Copic received a supplemental IMPACS grant (ID# 029969) to fund the activities of project director Howard aimed at completing the project and to pay for travel expenses to a meeting of IMPACS grantees.

The purpose of the IMPACS grant to the Alliance (ID# 023685) was similar to that of the first Copic grant: to design an administrative no-fault system and establish baseline data on medical injury and compensation by which its operation at demonstration sites could be evaluated. The grant did not cover implementation of the system. The Alliance anticipated additional private and public funding once the demonstration sites were selected and ready for operation.

In addition to hiring the Harvard team to conduct research, activities of the Alliance and its participating organizations included:

  • Negotiating a contract with HealthInsight, the Utah peer review organization, to oversee a review of approximately 5,000 discharge records from 13 Utah hospitals participating in the study.
  • Obtaining claims information from the Utah Medical Insurance Association and two large hospital entities for use by the Harvard team.
  • Forming a committee to analyze constitutional and legal issues and draft enabling legislation, and assembling a group of unpaid consultants to work on various aspects of the proposed no-fault system, including programs to monitor patient outcomes and reduce patient injuries. (For the names of the committee members and unpaid consultants, see Appendix 2.)
  • Meeting with hospital entities identified as prospective demonstration sites.
  • Serving as a liaison between the various Utah health-industry interests involved in the project and coordinating work with the Harvard team.

The Harvard Team

In addition to the medical injury analysis, the Harvard team's activities under its subcontracts included:

  1. Analyzing legal and constitutional obstacles to the implementation of no-fault in Colorado and Utah.
  2. Drafting model enabling legislation for Colorado.
  3. Studying administrative systems in effect in other jurisdictions, including Sweden, New Zealand, Florida, and Virginia.

Special attention was focused on the Swedish system, which requires an injury to be judged medically avoidable in order for the patient to be compensated. The Utah and Colorado project directors joined Brennan on a trip to Sweden to review the system's operation.

Subsequently, on recommendation of the IMPACS National Advisory Committee and National Program Office, RWJF awarded two grants directly to Brigham and Women's Hospital to support additional work by the Harvard team on the Colorado/Utah projects. These grants (ID#s 029907 and 032865) were designed to strengthen the methodology and results of the team's investigations.

Under Grant ID# 029907, the Harvard team:

  • Estimated the number of adverse events related to ambulatory care that were not detected in the original review of patient records, and calculated revised economic consequences for the two states.
  • Conducted an additional record review and analysis to understand more fully the incidence and costs of birth-related injuries.
  • Undertook additional analysis of legal obstacles and options for overcoming them, including consideration of generic issues of potential importance to other states interested in no-fault implementation.
  • Prepared a document summarizing the team's study findings.

Under Grant ID# 032865, the Harvard team conducted re-reviews of a random sample of 500 Colorado and Utah medical records in order to compare the reliability of two methods of determining adverse events from record reviews: (1) using two independent reviews plus a third to settle disagreements, and (2) using only two independent reviews but allowing the reviewers to make adverse event determinations based on a confidence score lower than the 4 (on a 6-point scale) required in the original study.

Methodology

The medical injury study conducted by the Harvard team involved the review of approximately 15,000 medical records of 1992 discharges randomly selected from a representative sample of 28 Colorado and Utah hospitals. The two-step review process — similar to the procedure used in the earlier Harvard Medical Practice Study of 1984 New York hospitalizations — was designed to detect adverse events. Nurses first screened all of the records; 2,868 of those met certain indications of an adverse event and were referred to physicians for further review. For each adverse event found, researchers and claims adjusters calculated the cost of the patient's resulting lost work time and lifetime health care needs. A judgment was also made on how preventable the event appeared to be.

The study team used these calculations to estimate the cost of a number of possible no-fault schemes — from a pure system covering all adverse events to a variety of more restrictive plans based on how serious and preventable the injury was. The team also figured the cost of compensating additional losses such as pain and suffering. Additionally, the team linked the results of the hospital record review with claims data provided by Colorado and Utah medical malpractice insurers. This permitted researchers to calculate to what extent medically injured patients in the two states were using the existing tort system.

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RESULTS

  • Data on medical injury rates and costs were generated and analyzed for Colorado and Utah, and estimates were made for the cost of a model no-fault compensation system in each state. Additionally, policy and legal issues critical to implementation of a no-fault system were investigated, and statutory language to implement such a system was drafted in preliminary form.
  • However, in both Colorado and Utah the preparation of an administrative system was not completed, and a no-fault system was never implemented. In Colorado, the political climate and the legislature's makeup changed during the course of the project, and as a result the Copic board of directors voted not to proceed. Project director Howard said the board feared an effort to seek enabling no-fault legislation would not only fail but might open up existing tort reforms to repeal attempts. Also, declining losses and premiums reduced Copic's interest in a new system, according to Howard. In Utah, project director Williams said the no-fault effort foundered when the state's dominant hospital chain declined to commit use of its Salt Lake City hospital as a demonstration site. The Alliance reported that ongoing stability in malpractice insurance premiums and the new system's projected costs diminished industry enthusiasm for no-fault, and that enactment of enabling legislation might be "more realistic" in the future.

Findings

Members of the Harvard team reported aspects of its Colorado-Utah study findings in a variety of publications. The following are from a comprehensive study overview published in the third quarter, 2000 issue of the Indiana Law Review:

  • The adverse event rate among hospitalized patients in each of the two states in 1992 was estimated to be 2.9 percent. In Utah, 169 adverse events were identified and in Colorado, 418. When weighted to reflect the states' population, those figures indicated 5,614 adverse events occurred among Utah patients and 11,578 among Colorado patients in 1992. In Utah, 32.6 percent of the adverse events were attributed to negligence and in Colorado, 27.5 percent.
  • Of all adverse events in the two states, 6.6 percent resulted in death; among negligent adverse events, the death rate was 8.8 percent. "In total, 439 patients hospitalized in Utah and Colorado in 1992 died due to negligent care; another 160 victims of negligence suffered grave or major disability."
  • Extrapolated to the full US population, the Utah-Colorado findings indicated that as many as 65,000 deaths occur a year in the nation due to adverse events. That is considerably fewer than the nearly 180,000 deaths nationally suggested by the results of the earlier Harvard Medical Practice Study of 1984 New York hospitalizations. The researchers said the disparity could result from differences in reviewer training, limitations in methodology, or simply better medical care in the two mountain states.
  • Instances of substandard care found in the Utah-Colorado records exceeded malpractice claims by a ratio of 5.1 to 1 in Utah and 6.7 to 1 in Colorado. The study identified 18 malpractice claims related to the reviewed records, and of those 18, only four "involved identifiable instances of negligence. Moreover reviewers had not even flagged the occurrence of an adverse event in 10" of the 18 claims. The results coupled with earlier studies "suggest that the dysfunctional characteristics of the medical malpractice system — most notably, its adequacy and accuracy — have a resilience over time and across jurisdictions when viewed through an epidemiological lens."
  • The cost of all adverse events in the two states in 1992, including health care costs, lost wages, and lost household production, totaled $661.9 million (in 1996 dollars), and nearly half of that — $308.3 million― resulted from preventable adverse events. Extrapolation indicates that nationally the cost of adverse events in 1996 dollars totaled approximately $38 billion — or $132 per capita.
  • Compensation of the cost of all adverse events in Colorado and Utah would substantially exceed the money currently spent on the medical malpractice systems in the two states. Malpractice premiums paid in 1996 totaled about $60 million in Utah and $100 million in Colorado.
  • However, costs of an administrative system can be significantly reduced by restricting compensation to injuries that meet the Swedish "avoidability" criteria and entail a disability period lasting a set number of weeks. With these restrictions, a system could include compensation for pain and suffering and still compare favorably in cost to the tort system.
  • The estimated annual cost of the preferred no-fault model for Utah was $54.9 million (in 1992 dollars) and for Colorado $82.0 million. The preferred models for the two states differed. Utah's was based on the Swedish criteria and a four-week disability prerequisite, and compensated health care costs, pain and suffering up to $100,000, and 66 percent wage replacement. Colorado's was based on the Swedish criteria and an eight-week disability prerequisite, and covered health care costs, pain and suffering, and full wage replacement. Neither paid for lost household production.

Limitations

The research team cautioned that the Colorado-Utah study results should be interpreted in light of several methodologic issues that could have caused either overestimation or underestimation of injury incidence and costs. In a paper submitted for publication on IMPACS-funded research under grant ID# 032865 comparing two methods of determining adverse events from record reviews, team members concluded, "Estimates of adverse event rates from medical record review … are highly sensitive to the degree of consensus and confidence among reviewers."

Communications

The findings of the Colorado and Utah studies became a key information source for a highly publicized report by the IOM on the pervasiveness of medical error. Although not directly related either to the Colorado-Utah no-fault projects or the IMPACS program, the report (entitled To Err Is Human: Building a Safer Health System) relied on the findings of the Colorado-Utah study and the earlier Harvard Medical Practice Study to conclude that medical errors cause at least 44,000 and possibly as many as 98,000 deaths a year in US hospitals. Even at the low end of the estimate, that would be more deaths than result from highway accidents, breast cancer, or AIDS. (The low end of the estimate was based on the Colorado-Utah findings, the high end on the earlier study of New York hospitals.) The report was controversial, with the project director of the Harvard team, Troyen A. Brennan, among the critics. Writing in the April 12, 2000 issue of The New England Journal of Medicine, Brennan said the two medical injury studies made no judgment on whether physician error was involved. (See the Bibliography for the full article citation.) Nevertheless, the IOM report focused attention on the problem of medical injuries and the need to improve patient safety.

Additionally, members of the Harvard team published 10 articles on the methodology, results, and policy implications of the Colorado-Utah study, including the overview of the project in the Indiana Law Review. (See the Bibliography for a full listing.) Harvard team members made six presentations to various professional groups, including an IMPACS-funded conference on medical malpractice at Duke University in September 1997. Additionally, the team's research received mention in academic journals and the general news media in connection with the IOM medical error report. The Alliance project received coverage in Salt Lake City's two major newspapers, Desert News and The Salt Lake Tribune.

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LESSONS LEARNED

  1. Would-be reformers of the medical malpractice compensation system should be aware that their efforts can be affected significantly by economic factors beyond their control. In both Colorado and Utah, the ongoing stability of the liability insurance market dampened enthusiasm for change among insurers and, as a result, legislators.
  2. Developers of a multisite hospital demonstration project should seek to identify the hospital participants as soon as possible and involve their top decision-makers in the planning process. The Utah project director said the effort to implement the no-fault demonstration project in that state might have been successful had the pilot sites been selected sooner and top leadership of the state's dominant hospital chain consulted earlier in the planning process.

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AFTER THE GRANT

Copic and the Alliance have no plans to renew efforts to implement an administrative no-fault system in their states, although they do not rule out that possibility in the future if the political reception and malpractice market change. RWJF has no plans to fund new no-fault efforts.

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GRANT DETAILS & CONTACT INFORMATION

Project

Feasibility of Alternative Compensation Plan for Iatrogenic Injuries

Grantee

Copic Medical Foundation (Denver,  CO)

  • Feasibility of Alternative Compensation Plan for Iatrogenic Injuries
    Amount: $ 823,169
    Dates: November 1994 to April 1996
    ID#:  022603

  • Transition to No-Fault Compensation Plan
    Amount: $ 19,320
    Dates: August 1996 to October 1996
    ID#:  029969

Contact

K. Mason Howard, M.D.
(303) 902-6652
ahoward583@aol.com

Grantee

Utah Alliance for Healthcare (Salt Lake City,  UT)

  • Implementation of a No-Fault Enterprise Liability Compensation Plan
    Amount: $ 627,932
    Dates: November 1994 to October 1996
    ID#:  023685

Contact

Elliott J. Williams, J.D.
(801) 521-5678
ewilliams@wilhunt.com

Grantee

Brigham and Women's Hospital (Boston,  MA)

  • Feasibility of Alternative Compensation Plan for Iatrogenic Injuries - Phase II
    Amount: $ 150,677
    Dates: August 1996 to July 1997
    ID#:  029907

  • Measure the Reliability of Two Chart Review Methods for Detecting Adverse Events
    Amount: $ 105,696
    Dates: October 1997 to June 1998
    ID#:  032865

Contact

Troyen A. Brennan, M.D., J.D., M.P.H.
(617) 732-8961
tabrennan@partners.org

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

COPIC Advisory Group

Susan Fox Buchanan
Attorney
Denver University Center for Health Policy and Ethics
Denver, Colo.

James E. Bye
Attorney
Holme, Roberts & Owen L.L.P.
Denver, Colo.

Edward Dauer
Professor and Dean Emeritus
Denver University School of Law
Denver, Colo.

George Dikeou
Attorney and Chair of Legislative Activities
Copic Insurance Co.
Denver, Colo.

Joel Edelman
Former Chief Executive Officer
Rose Medical Center
Denver, Colo.

Richard Lamm
Former Governor of Colorado
Director, Denver University Center for Health Policy and Ethics
Denver, Colo.

Dennis Lynch
Dean
Denver University School of Law
Denver, Colo.

Stephen H. Shogan, M.D.
Neurosurgeon
Denver, Colo.


Appendix 2

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

EPIC Legal Advisory Committee

Michael E. Dyer
Blackburn & Stoll, L.C.
Salt Lake City, Utah

David B. Erickson
Intermountain Health Care, Inc.
Salt Lake City, Utah

Leslie P. Francis
University of Utah College of Law
Salt Lake City, Utah

L. Paul Palmer
Salt Lake City, Utah

Karie L. Minaga-Miya
Lakeview Hospital
Bountiful, Utah

Constance B. White
Director
Public Service Commission
Salt Lake City, Utah

David G. Williams
Snow, Christensen & Martineau
Salt Lake City, Utah

Unpaid Consultants to the EPIC Project
Joan C. Abele, M.D.
Salt Lake City, Utah

Don B. Allen
Ray, Quinney & Nebeker
Salt Lake City, Utah

Val J. Bateman
Utah Medical Association
Salt Lake City, Utah

Margene Bortel
Health Insight
Salt Lake City, Utah

Leslie P. Francis
University of Utah College of Law
Salt Lake City, Utah

David Gessel
Utah Association of Health Care Providers
Salt Lake City, Utah

Brent C. James, M.D.
Intermountain Health Care, Inc.
Salt Lake City, Utah

Susan Horn, Ph.D.
LDS Hospital
Salt Lake City, Utah

K. Mason Howard, M.D.
COPIC
Englewood, Utah

Richard B. Kinnersley
President
Utah Association of Health Care Providers
Salt Lake City, Utah

L. Paul Palmer
Salt Lake City, Utah

J. Leon Sorenson
Utah Medical Association
Salt Lake City, Utah

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Brennan TA. "The Institute of Medicine Report on Medical Errors — Could It Do Harm?" New England Journal of Medicine, 342(15): 1123–1125, 2000.

Gawande AA, Thomas EJ, Zinner JM and Brennan TA. "The Incidence and Nature of Surgical Adverse Events in Colorado and Utah in 1992." Surgery, 126(July): 66–75, 1999. Abstract available online.

Petersen SK. "No-Fault and Enterprise Liability: The View from Utah." Annals of Internal Medicine, 122(6): 462–463, 1995.

Studdert DM, Brennan TA and Thomas EJ. "Beyond Dead Reckoning: Measures of Medical Injury Burden, Malpractice Litigation, and Alternative Compensation Models from Utah and Colorado." Indiana Law Review, 33(4): 1643–1686, 2000.

Studdert DM, Thomas EJ, Burstin HR, Zbar BIW, Orav EJ and Brennan TA. "Negligent Care and Malpractice Claiming Behavior in Utah and Colorado." Medical Care, 38(3): 250–260, 2000. Abstract available online.

Studdert DM, Thomas EJ, Zbar BIW, Newhouse JP, Weiler PC, Bayuk J and Brennan TA. "Can the United States Afford A 'No-Fault' System of Compensation for Medical Injury?" Law and Contemporary Problems, 60(Spring): 1–34, 1997.

Thomas EJ and Brennan TA. "Incidence and Types of Preventable Adverse Events in Elderly Patients: Population Based Review of Medical Records." British Medical Journal, 320(March 18): 741–744, 2000.

Thomas EJ, Lipsitz SR, Studdert DM and Brennan TA. "The Reliability of Medical Record Review for Estimating Adverse Event Rates." Annals of Internal Medicine, 136(11): 812–816, 2002. Abstract available online.

Thomas EJ, Orav EJ, and Brennan TA. "Hospital Ownership and Preventable Adverse Events." Journal of General Internal Medicine, 15(4): 211–219, 2000. Abstract available online.

Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, Howard KM, Weiler PC and Brennan TA. "Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado." Medical Care, 38(3): 261–271, 2000. Abstract available online.

Thomas EJ, Studdert DM, Newhouse JP, Zbar BIW, Howard KM, Williams EJ and Brennan TA. "Costs of Medical Injuries in Utah and Colorado." Inquiry, 36(3): 255–264, 1999. Abstract available online.

Reports

Howard KM, Thomas E, Studdert D, Zbar B, Burstin H and Brennan TA. Draft Interim Report: Colorado Medical Practice Study. March 22, 1996.

Economic Consequences of Birth-Related Injury. Undated.

Harvard School of Public Health Report on Robert Wood Johnson Subcontracts, IMPACS Program, Part I: Empirical Investigations. November 1, 1995.

Harvard School of Public Health Report on Robert Wood Johnson Subcontracts, IMPACS Program, Part 2: Policy and Legal Analysis. November 1, 1995.

Presentations and Testimony

Eric J. Thomas, "Designing No-Fault Medical Malpractice Alternatives: Two New Approaches," at the Fall Research Conference of the Association for Public Policy Analysis and Management, October 28–30, 1996, Pittsburgh.

Troyen A. Brennan, Panel Presentation on No-Fault Compensation, at a briefing for journalists and congressional staff sponsored by the IMPACS Program, American Academy of Actuaries, and Alliance for Health Reform and entitled "Patients, Providers, Insurers: Who's the Injured Party?" November 22, 1996, Washington.

Eric J. Thomas, "Incidence of and Risk Factors for Adverse Events and Negligence in Utah and Colorado," at the National Meeting of the Society of General Internal Medicine, May 1–3, 1997, Washington.

Eric J. Thomas, "Costs of Alternative Approaches to Compensating Medical Injuries," at the National Meeting of the Society of General Internal Medicine, May 1–3, 1997, Washington.

Troyen A. Brennan and David M. Studdert, "Can the United States Afford a 'No-Fault' System of Compensation for Medical Injury?" at the IMPACS/Duke Medical Malpractice Conference, September 12–13, 1997, Durham, NC.

Troyen A. Brennan, member of panel discussion entitled "How Can Consumers Be Protected in the Health Care Market Place?" at the Annual Meeting of the Association for Health Services Research, June 28, 1999, Chicago.

Print Coverage

A selection of articles in newspapers and other print media that referenced the Colorado-Utah medical injury research findings in connection with the Institute of Medicine's 1999 report on medical errors (To Err is Human: Building a Safer Health System):

  • "Group Asking U.S. for New Vigilance in Patient Safety," in The New York Times, November 30, 1999.
  • "Medical Errors Blamed for Many Deaths; As Many As 98,000 a year in US Linked to Mistakes," in The Washington Post, November 30, 1999.
  • "Medical Errors Kill Thousands, Panel Says; Safety: The Toll May Be As High As 98,000 Yearly, A U.S.-Funded Report States, and It Calls for Several Reforms," in Los Angeles Times, November 30, 1999.
  • "Deaths Due to Medical Errors Are Exaggerated in the Institute of Medicine Report" and "Institute of Medicine Medical Error Figures Are Not Exaggerated," in The Journal of the American Medical Association, July 5, 2000.
  • "Report on Medical Errors Called Erroneous," in The Washington Post, July 5, 2000.
  • "How Many Deaths Are Due to Medical Error? Getting the Number Right," and "Media Mistakes in Coverage of the Institute of Medicine's Error Report," in Effective Clinical Practice, November/December, 2000.

News Articles and commentary in national print media specifically about the Colorado and Utah projects included:

  • "The No-Fault Approach," in Business Insurance, August 29, 1994.
  • "Fatal Distraction: Finance vs. Vigilance in Our Nation's Hospitals," in Journal of General Internal Medicine, April, 2000.

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Report prepared by: Michael H. Brown
Reviewed by: Robert Crum
Reviewed by: Marian Bass
Program Officer: Joel C. Cantor
Program Officer: Beth A. Stevens
Program Officer: Judith Y. Whang

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