VA Health Care: Trends in Malpractice Claims Can Aid in Addressing
Quality of Care Problems (Letter Report, 12/21/95, GAO/HEHS-96-24).

Pursuant to a congressional request, GAO reviewed the Department of
Veterans Affairs' (VA) malpractice claims, focusing on the: (1) total
number of malpractice claims filed against VA between fiscal years (FY)
1990 and 1994; (2) way VA manages its malpractice claims; (3) extent to
which malpractice experiences are used in VA quality assurance
activities; and (4) volume of non-VA health care malpractice claims.

GAO found that: (1) between FY 1990 and 1994, malpractice claims against
VA medical centers (VAMC) increased from 678 to 978 and claimants
received over $200 million in payments; (2) in 1992, VA entered into an
agreement with the Armed Forces Institute of Pathology (AFIP) to analyze
malpractice claims on a systemwide basis to identify malpractice trends
and risk management issues, but VA is not using the information
requested from AFIP to address risk management or quality assurance
issues; (3) Department of Defense (DOD) malpractice data can not easily
be compared to VA data due to the lack of a standard data collection
format; and (4) DOD malpractice data may help VA identify areas in which
malpractice claims are being generated, such as surgery-related
incidents.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-96-24
     TITLE:  VA Health Care: Trends in Malpractice Claims Can Aid in 
             Addressing Quality of Care Problems
      DATE:  12/21/95
   SUBJECT:  Malpractice (medical)
             Quality assurance
             Risk management
             Internal controls
             Veterans benefits
             Patient care services
             Claims settlement
             Physicians
             Veterans hospitals
IDENTIFIER:  HHS National Practitioner Data Bank
             
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Cover
================================================================ COVER


Report to the Ranking Minority Member, Committee on Veterans'
Affairs, U.S.  Senate

December 1995

VA HEALTH CARE - TRENDS IN
MALPRACTICE CLAIMS CAN AID IN
ADDRESSING QUALITY OF CARE
PROBLEMS

GAO/HEHS-96-24

VA Health Care Malpractice Claims

(101472)


Abbreviations
=============================================================== ABBREV

  AFIP - Armed Forces Institute of Pathology
  DOD - Department of Defense
  VA - Department of Veterans Affairs
  VAMC - Veteran's Affairs Medical Center

Letter
=============================================================== LETTER


B-266073

December 21, 1995

The Honorable John D.  Rockefeller IV
Ranking Minority Member
Committee on Veterans' Affairs
United States Senate

Dear Senator Rockefeller: 

In fiscal year 1994, the federal government paid about $54 million in
settlements and judgments to cover about 400 malpractice claims
against the Department of Veterans Affairs (VA).  Research indicates
that the number of malpractice claims filed against, or resulting in
payment on behalf of, a facility or practitioner does not necessarily
indicate that substandard care was provided to a patient.  However,
analysis of settled malpractice claims can be a useful risk
management technique to (1) determine if the quality of care being
provided by either a facility or practitioner needs review, (2)
identify problem-prone clinical processes, and (3) establish a
corrective action plan.\1

In view of your interest in the issue of VA's malpractice claims, you
asked us to (1) identify the total number of malpractice claims made
against VA during fiscal years 1990 through 1994, (2) examine the way
in which VA manages its malpractice claims, (3) determine the extent
to which the malpractice experience of facilities or individual
practitioners is used in VA quality assurance activities, and (4)
compare VA's volume of malpractice claims with those of non-VA health
care entities and organizations.\2 You also asked us to determine the
extent to which individual malpractice experience is reported to the
National Practitioner Data Bank.  In our July 7, 1995, report, VA
Health Care:  Physician Peer Review Identifies Quality of Care
Problems but Actions to Address Them Are Limited (GAO/HEHS-95-121),
we responded to this specific request by reporting on VA's record
with respect to reporting to the National Practitioner Data Bank
those practitioners on whose behalf malpractice payments have been
made. 

In performing our current review, we collected, compared, and
analyzed malpractice claim information from VA's Central Office in
Washington, D.C., the Department of Defense (DOD), the National
Practitioner Data Bank, and the Armed Forces Institute of Pathology
(AFIP); reviewed VA policies and procedures involving the processing
of malpractice claims; interviewed DOD officials and attorneys in
VA's Office of General Counsel to determine their role in the
processing of malpractice claims; and talked with the directors of
quality assurance and risk management programs at the six VA medical
centers (VAMC) we visited during a prior review on physician peer
review to determine how they use malpractice claims information in
their respective programs.\3 We performed our work between May and
October 1995 in accordance with generally accepted government
auditing standards. 


--------------------
\1 R.  Kravitz and others, "Malpractice Claims as a Quality
Improvement Tool," Journal of the American Medical Association, Vol. 
266, No.  15 (Oct.  16, 1991), p.  2087. 

\2 During this review, we focused on malpractice claims filed against
the Army, Navy, and Air Force because similar data were not available
from the private sector companies we contacted. 

\3 VAMCs visited were as follows:  Martinsburg, West Virginia;
Cleveland, Ohio; Houston, Texas; Hines-Chicago, Illinois; St.  Louis,
Missouri; and Fayetteville, North Carolina. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

From fiscal year 1990 to fiscal year 1994, malpractice claims against
VAMCs have steadily increased, from 678 to 978, with payments made to
claimants totaling over $200 million.  In 1992, VA entered into an
agreement with AFIP to perform analysis of and trends in VA
malpractice claims, recognizing that it needs to analyze malpractice
claims on a systemwide basis in order to identify malpractice trends
and risk management issues.  However, limited use is being made of
the VA-requested information developed by AFIP by either VA's Office
of Quality Assurance or risk management and quality assurance
personnel in individual VAMCs. 

Although malpractice claim information is available from DOD, it is
not comparable to the malpractice data that VA collects.  The primary
reason for the lack of comparability is the absence of a standard
data collection format.  Nonetheless, we found that DOD information
may be useful to VA to draw comparisons in areas in which malpractice
claims are being generated, such as surgery-, diagnosis-, and
medication-related incidents. 


   BACKGROUND
------------------------------------------------------------ Letter :2

VA operates 158 medical centers and employs approximately 10,723
full- and part-time physicians and 37,294 registered nurses.  During
fiscal year 1994, these facilities treated approximately 906,925
inpatients and provided for 24,074,365 outpatient visits.  VA
acknowledges that patient care, particularly that which occurs in
hospitals, contains some degree of inherent risk.  In some instances
it is difficult to differentiate between the risk of incurring
malpractice claims from not treating diseases and the risk of
incurring such claims from proceeding with treatment.  Under the
provisions of the Federal Tort Claims Act\4 (title 28 U.S.C. 
2671-2680), the federal government may be held responsible for
monetary damages for personal injury or wrongful death caused by the
negligent actions of its employees when they are operating within the
scope of their employment.  Thus, the government assumes liability
for any such actions by VA practitioners if they were performed in
the line of duty. 

VA's Office of General Counsel has overall responsibility for
managing the malpractice claims process.  However, the routine
investigation, analysis, and decision-making involved in processing
each claim is conducted by one of VA's 23 regional counsels located
throughout the United States.  Specifically, regional counsel staff
examine the initial claim, interview the VA health care provider(s)
involved, and obtain an independent medical opinion on the
circumstances of the claim--usually from peer reviewers in a VAMC
other than the center involved in the claim.  On the basis of this
information, the regional counsel can either deny or settle the case. 
If a claim is denied, the claimant may appeal it within VA or file
suit in federal district court.  Litigation is defended by the U.S. 
Attorney with the assistance of the regional counsel and the Office
of General Counsel.  No court action can be initiated until the
claimant has presented his/her claim administratively and had it
denied. 

When an investigation has been completed by regional counsel, a
complete, concise, and accurate statement of the relevant facts must
be prepared by the cognizant attorney.  The statement of facts must
be supported by appropriate exhibits and references.  Because of
their confidential and privileged nature, however, quality assurance
records and documents may not be included as exhibits to the
statement.  If a suit is filed, the completed statement of facts is
to be reviewed by attorneys in the Office of General Counsel and
appropriate VA medical personnel.  It is also to be reviewed by
attorneys in the Department of Justice.  Case files are maintained by
regional counsels in a computerized database to which VA's General
Counsel has complete access. 

A claim may be settled by regional counsel for amounts up to
$100,000.  Settlements above that amount but not exceeding $200,000
may be settled by VA's General Counsel.  Sums above $200,000 are
negotiated by the General Counsel subject to approval by the
Department of Justice.  In fiscal year 1994, 252 administrative
claims were settled by VA's regional counsels and General Counsel at
a cost of $19.6 million; 127 lawsuits were settled by the Department
of Justice and the U.S.  Attorney at a cost of $30.6 million; and 12
cases resulted in court judgments against the federal government
totaling $3.6 million. 


--------------------
\4 The Federal Tort Claims Act protects federal employees from
personal liability for common law torts (wrongs) committed within the
scope of their employment, while providing persons injured by the
common law torts of federal employees with an appropriate remedy
against the United States. 


   MALPRACTICE CLAIMS MADE AGAINST
   VA ARE INCREASING
------------------------------------------------------------ Letter :3

The number of malpractice claims filed annually against VA has
increased from 678 in fiscal year 1990 to 978 in fiscal year 1994. 
Correspondingly, the monetary payments made on 943 administrative
claims settled during this period have increased from approximately
$10 million in fiscal year 1990 to $20 million in fiscal year 1994. 
In addition, the 1,089 lawsuits filed against VA have resulted in
annual litigated settlements and awards to claimants ranging from $22
million in fiscal year 1990 to $34 million in fiscal year 1994. 
Total payments made on behalf of VA for fiscal years 1990 through
1994 amounted to over $205 million with an average paid claim of
$120,714. 

VA classifies its malpractice claim data in two categories: 
administrative claims and lawsuits.  Every claim received in VA is
initially classified as administrative.  However, if a claim
subsequently results in a lawsuit and is filed in federal district
court, the claim entry is amended to reflect the new status, that is,
"suit filed" rather than "claim filed." Table 1 shows the number of
administrative cases filed and paid from fiscal year 1990 through
fiscal year 1994. 



                                Table 1
                
                 VA's Administrative Claim Experience,
                          Fiscal Years 1990-94

                                 Claims          Claims         Amount
Fiscal year    Claims filed     denied\a        settled\b         paid
-------------  -------------  -------------  ---------------  --------
1990                678            304             168        $9,854,7
                                                                    44
1991                672            346             152        9,868,96
                                                                     0
1992                749            383             183        13,284,3
                                                                    44
1993                801            406             188        16,640,3
                                                                    50
1994                978            667             252        19,640,0
                                                                    22
======================================================================
Total              3,878          2,106            943        $69,288,
                                                                   420
----------------------------------------------------------------------
\a Claims denied and closed without payment. 

\b A direct relationship between claims filed and claims settled or
denied in any one year does not necessarily exist, because the
settled or denied claim may have been filed during a previous fiscal
year. 

Lawsuits filed in federal district court may be settled before the
court makes a final judgment.  Table 2 shows the number and dollar
value of lawsuits filed in federal district court, the number of
claims settled before a court judgment was made, and the number and
dollar value of claims that resulted from a court judgment. 



                                Table 2
                
                 VA's Lawsuit Experience, Fiscal Years
                                1990-94


                                      Amount                    Amount
                       Number           paid     Number           paid
-----------  ------  -----------  ----------  ------------  ----------
1990            248      179      $20,090,59       6        $1,872,045
                                           3
1991            239      130      20,916,550       17        6,631,498
1992            228      141      18,427,452       18        9,089,489
1993            219      114      21,070,888       14        3,722,467
1994            155      127      30,628,483       12        3,596,292
======================================================================
Total         1,089      691      $111,133,9       67       $24,911,79
                                          66                         1
----------------------------------------------------------------------
The number of malpractice claims filed and paid is not necessarily
evidence that negligence has occurred.  Claims experience does,
however, provide the basis for examination of trends, identification
of problem areas, and an attempt to provide a systemwide vigorous
response through risk management programs.  VA recognizes this and in
June 1992 entered into an agreement with AFIP to analyze and assess
trends in VA malpractice claims.  The purpose of this effort was to
improve the quality of medical care in the VA system by providing VA
with information to (1) identify problem areas in delivery of care
and (2) initiate appropriate corrective actions.  The agreement with
AFIP pertains to all medical malpractice claims in the VA system that
were filed administratively on or after October 1, 1992. 

As of October 1995, AFIP had issued one report (April 1994) to VA.\5

This report contains an analysis of the 801 medical malpractice
claims filed against VA in fiscal year 1993 and is intended to
provide VA management with some general characteristics of VA
malpractice claims in order to help VA managers identify possible
opportunities for improving VA health care delivery.  AFIP's report
was provided by VA's Office of Quality Management to all medical
center quality managers for their review. 

Because this was the first report prepared by AFIP, no data trends
could be noted.  However, examples of the types of analysis that the
report contained were as follows: 

  The average time between the date of the incident and the date the
     case was closed (both administratively closed and closed by
     litigation) was 3.62 years. 

  The three most frequent age groups filing medical malpractice
     claims were beneficiaries between the ages of 61 and 70 (29.5
     percent); 41 and 50 (22.8 percent); and 51 and 60 (18.1
     percent). 

  In three-fourths of all malpractice cases filed, there was either
     major injury (53.9 percent) or death (28.2 percent). 

  The most frequently recorded clinical specialty involved in
     malpractice claims was internal medicine (13.1 percent).  Less
     frequently listed specialties were general surgery (8.7
     percent), psychiatry (7.8 percent), orthopedic surgery (6.7
     percent), and nursing (5.4 percent). 

  The three most frequent locations where alleged incidents occurred
     were the operating suite (23.8 percent), the patient's room
     (23.5 percent), and the outpatient area (17.2 percent). 

  For the eight components of care reviewed by AFIP, the care was
     either "definitely acceptable," or "probably acceptable" in 75
     to 80 percent of the cases.\6 According to the peer reviewer at
     the facility, in approximately 64 percent of the cases, most
     experienced competent practitioners would have handled the case
     similarly in all respects.  In approximately 20 percent of the
     cases, most experienced competent practitioners might have
     handled the case differently in one or more respects, and in 9
     percent of the cases, most experienced practitioners would have
     handled the cases differently in all respects. 

  Staff physicians constituted 61.2 percent of the various providers
     involved in the alleged incidents, and physicians in training
     (residents or fellows) constituted 32.7 percent of the total. 

  In approximately one-half of the claims filed, the duration of the
     injury caused by the alleged negligence was permanent.\7


--------------------
\5 AFIP's agreement with VA requires an annual report of AFIP
findings to VA.  AFIP's report on its analysis of claims filed in
fiscal year 1994 is in the final stages of editing by AFIP and is
currently being reviewed by VA. 

\6 The components of care measured by AFIP include such questions as
(1) Was the correct diagnosis made?  (2) Was the proper
therapy/treatment selected?  (3) Was the treatment technique
performed correctly?  and (4) Was the patient's condition properly
monitored by the physician? 

\7 Department of Veterans Affairs Medical Malpractice Report Tort
Claim Information System, Fiscal Year 1993, AFIP, Department of Legal
Medicine (Apr.  15, 1994), pp.  5-10. 


   DATA ON MALPRACTICE CASES ARE
   NOT CONSISTENTLY USED IN VAMC
   QUALITY ASSURANCE OR RISK
   MANAGEMENT PROGRAMS
------------------------------------------------------------ Letter :4

Quality assurance personnel in the six VAMCs we visited are not
consistently using available malpractice claim information in either
their quality assurance or risk management programs.  For example, of
the 53 claims paid in fiscal year 1994 that were associated with
practitioners in these facilities, we found only 12 cases where there
was evidence that defined follow-up action was taken on the risk
management issues specified in the tort claim.  Further, recent
discussions with quality assurance personnel at these facilities
revealed that the analysis of malpractice claims being made for VA by
AFIP is not consistently being used by medical center personnel to
improve quality of care. 

Only one of the six risk management and/or quality assurance
personnel we interviewed indicated that she is using AFIP information
in the center's risk management program.  This Risk Manager has
established a system for reviewing and tracking all malpractice
claims filed for the medical center.  Specifically, information from
AFIP's report is compared with the medical center's claims database
to present a comprehensive picture of malpractice experience of the
medical center.  This information assists the center's risk
management and quality assurance personnel in analyzing and assessing
trends in malpractice data.  Of the remaining personnel we
interviewed, two told us that they had not seen AFIP's report, and
three stated that they had read the report.  However, those three
individuals did not indicate that they used the data in their risk
management program.  A copy of the report was usually given by the
VAMC's chief of staff to the relevant service chiefs for follow-up. 
The service chiefs use the information in their clinical service
meetings with the medical staff. 

The Risk Manager at one of the VAMCs we visited told us that VA is
also replacing its Patient Incident Review guidelines with guidelines
for an "Integrated Risk Management Program." The revised guidelines
call for VAMCs to focus on correcting problems using claims analysis
information obtained from AFIP's annual report.  However, AFIP's
annual report contains VA systemwide claims data and analysis and
does not have information specific to any VAMC.  These data are
available upon request. 

AFIP can provide VAMCs with the number of malpractice cases at the
facility, the status of a case, the amount of payment, the results of
peer review, a determination about whether the patient injury was
related to a component of care, and the types of risk management
issues that should be addressed.  According to an official in AFIP,
at least one VAMC, the identity of which he could not recall, and a
regional office requested this information in fiscal year 1994.  The
Chief of Staff for the region involved told us that he requested
claim analysis information for every VAMC in his region in order to
(1) determine what corrective actions are being taken at each
facility to preclude a repetition of the event that resulted in a
malpractice claim and (2) review the decisions made by VAMC personnel
with respect to reporting a practitioner on whose behalf a
malpractice payment was made to the National Practitioner Data Bank. 


   USEFULNESS OF MALPRACTICE CLAIM
   INFORMATION FROM DOD HEALTH
   CARE ENTITIES
------------------------------------------------------------ Letter :5

The methods used by VA and the uniformed services to collect and
present malpractice claim data are not consistent.  Thus, no valid
comparison can be made of their claim data.  Comparisons can,
however, be made of the types of problems that are resulting in
malpractice claims against each of these entities.  Table 3 shows the
areas into which most malpractice claims fall. 



                                Table 3
                
                    Major Negligence Allegations, by
                       Percentage of Claims Filed

                                                                   Air
                                                                Force\
Allegation                                  VA    Army    Navy       a
--------------------------------------  ------  ------  ------  ------
Diagnosis related                           26      41      42      37
Treatment related                           31      15       7      40
Wrongful death                              \b      \b      \b    16\c
Medication related                          15       4       6      \b
Monitoring                                   5      \b      \b      \b
Surgery related                             24      20      14      \b
Obstetrics related                          \b      16      22      \b
----------------------------------------------------------------------
Note:  The figures for the Army, Navy, and Air Force were derived
from 1992 data.  Information on VA was derived from 1993 data. 

\a The Air Force used the codes within the treatment-related category
for three of its allegations.  When combined, this reduces the Air
Force's top five to a top three. 

\b Data not provided for these categories. 

\c Not otherwise classified. 

Appendix II shows the elements within six types of malpractice claim
allegations in table 3. 

During fiscal years 1990 through 1994, 5,172 malpractice claims were
filed against the Army, Navy, and Air Force (see app.  I for a claims
breakout by uniformed service).  During the same period, 3,878
malpractice claims were filed against VA.  Accurate comparisons of
these data cannot be made because there is no standard interagency
format for data collection and presentation.  As a result, each
entity uses its own criteria (for example, data presented on a
calendar or fiscal year basis, or multiple claims on a single case
incorporated in the count as opposed to recording only a single
malpractice case). 

But, even if the number of malpractice claims filed against VA and
the military services could be compared, the numerical data may not
be an accurate representation of the extent to which malpractice in
fact occurs.  For example, research indicates that patients who have
relatively low incomes and/or are over the age of 65 are less likely
to file malpractice claims than younger patients.\8 Given that the
preponderance of patients in VA are over the age of 65, it can be
expected that not all malpractice activity will be reported.\9

Further, the "Feres Doctrine" limits government liability for
monetary damages for injuries sustained by active duty service
members.  Specifically, under this doctrine the government is not
liable in monetary damages for injuries to active duty service
members that occur in the course of activity incident to service.\10

Consequently, active duty members are not compensated under the
Federal Tort Claims Act for injuries they may receive in military
hospitals as the result of malpractice. 


--------------------
\8 This fact does not contradict the previously cited AFIP analysis
of 1993 claim information that approximately 30 percent of the
malpractice claims filed involved patients aged 61 to 70.  More than
40 percent of the individuals receiving health services in VA are
over age 65.  Consequently, the greater percentage of malpractice
claims made will occur in this age group, which also has a high rate
of comorbidity. 

\9 See M.  Sager and others, "Do the Elderly Sue Physicians?"
Archives of Internal Medicine, Vol.  150 (May 1990), p.  1091; T. 
Brennan and others, "Incidence of Adverse Event and Negligence in
Hospitalized Patients," New England Journal of Medicine, Vol.  324,
No.  6 (Feb.  7, 1992), p.  372; and Medical Malpractice: 
Medicare/Medicaid Beneficiaries Account for a Relatively Small
Percentage of Malpractice Losses (GAO/HRD-93-126, Aug.  11, 1993), p. 
11. 

\10 Although active duty members are not compensated for injuries
they receive as a result of malpractice in military hospitals, VA
administers a comprehensive system of benefits designed to compensate
for injuries or deaths caused by treatment in military facilities
resulting from active military service. 


   CONCLUSIONS
------------------------------------------------------------ Letter :6

The growing number of malpractice claims involving VA practitioners
and facilities raises concerns about risk management and quality
assurance at VAMCs.  Through AFIP, VA has the ability to obtain
detailed analysis of and descriptions of trends in malpractice data
from both a systemwide and medical center perspective.  Although
claims analysis is but one segment of a comprehensive risk management
program, effective utilization of these data is important.  However,
AFIP data are not being effectively utilized at either the central
office or VAMC level.  As a result, opportunities to (1) identify
possible systemic risk management problems and/or individual provider
inefficiencies and (2) decrease the risk of incurring future
malpractice claims are being lost. 


   RECOMMENDATIONS
------------------------------------------------------------ Letter :7

We recommend that the Secretary of Veterans Affairs direct the Under
Secretary for Health to require VAMC directors to obtain and utilize
all available AFIP data, including facility-specific data, to (1)
identify problem-prone clinical processes and (2) initiate programs
to prevent recurrence of adverse events that caused malpractice
claims to be generated. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :8

On November 3, 1995, we obtained comments on a draft of this report
from VA's Deputy Under Secretary for Health, other Veterans Health
Administration officials, and VA's General Counsel.  The Deputy Under
Secretary generally concurred with our recommendations that VA and
the individual facilities review and utilize available data relating
to malpractice claims.  He stated that although the report indicates
a sizable increase in malpractice claims, the increase has been
modest and similar to increases in claims filed and paid by DOD and
the private sector.  In addition, he noted that by focusing on claims
filed and paid only since 1990, our report fails to recognize that
VA's claims experience tends to be cyclical, as evidenced by the
trend in the 1980s when increases in claims were followed by
decreases later in the decade. 

We noted in our report that the number of malpractice claims filed
and paid is not necessarily evidence of negligence; however, claims
experience is valuable in examining trends, identifying problems, and
establishing risk management strategies.  Although we did not take
into specific account VA's cyclical experience with malpractice
claims during the 1980s, we continue to believe that VA's recent
experience with claims filed and paid provides an opportunity for
enhancement of VA's quality assurance programs by analyzing, both at
headquarters and locally, the reasons the claims were filed.  VA
officials agree with this point.  In response to the comments of VA's
General Counsel, we made several technical changes to the draft
report as we believed appropriate. 


---------------------------------------------------------- Letter :8.1

As agreed with your office, copies of this report will be sent to
appropriate congressional committees; the Secretary of Veterans
Affairs; the Director, Office of Management and Budget; and other
interested parties.  We will make copies available to others upon
request. 

If you have questions about this report, please contact me at (202)
512-7120.  Major contributors to this report were James A.  Carlan,
Assistant Director; and Patricia A.  Jones, Evaluator-in-Charge. 

Sincerely yours,

David P.  Baine
Director, Health Care Delivery
 and Quality Issues


DOD TORT CLAIM EXPERIENCE BY
SERVICE BRANCH, FISCAL YEARS
1990-94
=========================================================== Appendix I



                                        Table I.1
                         
                                U.S. Army Claim Experience

                                  Appeal
Fiscal                    Claims       s      Claims                     Suits     Suits
year        Claims filed  denied  denied        paid   Amount paid       filed      paid
----------  ------------  ------  ------  ----------  ------------  ----------  --------
1990                 710     286      39         223   $18,574,969          \a        \a
1991                 557     355      37         202    21,036,665          \a        \a
1992                 584     283      40         174    19,015,223          \a        \a
1993                 588     273      29         191    27,632,880          \a        \a
1994                 653     264      30         210    22,166,807          \a        \a
========================================================================================
Total              3,092   1,461     175       1,000  $108,426,544         104       192
----------------------------------------------------------------------------------------


                                        Table I.2
                         
                                U.S. Navy Claim Experience

Calendar      Claims  Judgment                               Suits                 Suits
year           filed         s   Amount paid  Dismissals   settled   Amount paid  denied
------------  ------  --------  ------------  ----------  --------  ------------  ------
1990             120         5   $11,522,466          14        69   $15,388,770      51
1991             133         3     6,084,575          36        73    16,110,968      63
1992             115         3     3,425,500          25        70    10,626,862      37
1993             121         2       120,000          19        62    16,711,124      28
1994             148         0             0          16        58    15,403,032      43
========================================================================================
Total            637        13   $21,152,541         110       332   $74,240,756     222
----------------------------------------------------------------------------------------


                                        Table I.3
                         
                             U.S. Air Force Claim Experience

Fiscal                    Administrative      Amount       Suits     Suits
year        Claims filed  claims settled        paid       filed      paid   Amount paid
----------  ------------  --------------  ----------  ----------  --------  ------------
1990                 301             284  $4,570,693         212        63   $23,896,474
1991                 268             264   7,426,345         184        65    25,396,650
1992                 315             256   9,011,778         164       109    16,104,352
1993                 287             317  13,965,621         178       104    19,780,464
1994                 272             272   8,481,288         200        79    23,512,651
========================================================================================
Total              1,443           1,393  $43,455,72         938       420  $108,690,591
                                                   5
----------------------------------------------------------------------------------------
\a U.S.  Army Litigation Division provided only 5-year aggregate
information for these categories. 


MALPRACTICE CLAIMS DESCRIPTION
CODES
========================================================== Appendix II

Code number                              Description
---------------------------------------  ---------------------------------------
Diagnosis related
--------------------------------------------------------------------------------
010                                      Failure to diagnose (that is,
                                         concluding that patient has no disease
020                                      or condition worthy of further follow-
                                         up or observation)
030                                      Wrong diagnosis or misdiagnosis (that
040                                      is, original diagnosis is incorrect)
050                                      Improper performance of test
060                                      Unnecessary diagnostic test
                                         Delay in diagnosis
                                         Failure to obtain consent/lack of
                                         informed consent


Surgery related
--------------------------------------------------------------------------------
210                                      Failure to perform surgery
220                                      Improper positioning
230                                      Retained foreign body
240                                      Wrong body part
250                                      Improper performance of surgery
260                                      Unnecessary surgery
270                                      Delay in surgery
280                                      Improper management of surgical
285                                      patient
                                         Failure to obtain consent/lack of
                                         informed consent


Medication related
--------------------------------------------------------------------------------
305                                      Failure to order appropriate
310                                      medication
315                                      Wrong medication ordered
320                                      Wrong dosage ordered of correct
325                                      medication
330                                      Failure to instruct on medication
340                                      Improper management of medication
350                                      regimen
355                                      Failure to obtain consent/lack of
360                                      informed consent
365                                      Medication error
370                                      Failure to medicate
380                                      Wrong medication administered
                                         Wrong dosage administered
                                         Wrong patient
                                         Wrong route
                                         Improper technique


Obstetrics related
--------------------------------------------------------------------------------
505                                      Failure to manage pregnancy
510                                      Improper choice of delivery method
520                                      Improperly performed vaginal delivery
525                                      Improperly performed C-section Failure
540                                      to obtain consent/lack of informed
550                                      consent
555                                      Improperly managed labor
560                                      Failure to identify/treat fetal
                                         distress
570                                      Delay in treatment of fetal distress
575                                      (that is, identified but treated in
580                                      untimely manner)
                                         Retained foreign body/vaginal/uterine
                                         Abandonment
                                         Wrongful life/birth


Treatment related
--------------------------------------------------------------------------------
610                                      Failure to treat
620                                      Wrong treatment/procedure performed
                                         (also improper choice of treatment or
630                                      procedure)
640                                      Failure to instruct patient on self
650                                      care
660                                      Improper performance of a treatment or
665                                      procedure
670                                      Improper management of course of
675                                      treatment
680                                      Unnecessary treatment
685                                      Delay in treatment
                                         Premature end of treatment (also
                                         abandonment)
                                         Failure to supervise treatment/
                                         procedure
                                         Failure to obtain consent for
                                         treatment/lack of informed consent
                                         Failure to refer/seek consultation


Monitoring
--------------------------------------------------------------------------------
710                                      Failure to monitor
720                                      Failure to respond to patient
730                                      Failure to report on patient condition
--------------------------------------------------------------------------------
Source:  Adopted from the Harvard Risk Management Foundation
Allegations of Negligence by the National Practitioner Data Bank. 


*** End of document. ***