Danish Malpractice System Provides Integrity, Safety, and an Education Resource

It is depressingly common and it has recently happened here in Australia.
A patient leaves hospital, or a doctor’s surgery or from a pharmacy with a medication such as Methotrexate with instructions stating “one tablet daily” instead of “one tablet weekly”.
The patient is damaged or dies, and there begins the problem of who to blame and how much to sue for in a court of law for compensation, if indeed the patient or their families are able to afford it.
The lid is screwed down tightly on accurate information as the lawyers and the insurance companies move in to take control.

Such was a recent case in Denmark, where a patient had a distressingly close call after being discharged from Rigshospitalit, the Danish national hospital.
The patient was under the care of liver specialist Dr Ole Hamberg, and he decided to investigate the cause of the error and why it was not picked up.
He very quickly found that the hospital’s doctor’s prescribing system was mistakenly advising doctors (through prompts) to prescribe methotrexate daily, instead of once or twice a week.
Many patients throughout Denmark were being poisoned, and Dr Hamberg made sure they were all contacted and corrections made to their dosing schedules.
And, of course, the prescribing system was fixed.
The problem magically disappeared.

The moral of this story is that Denmark has a unique reporting system in that it has a national database for recording this type of problem (in fact any error from any level of all health professions) backed by a national program to financially compensate victims of patient harm.
Nobody is blamed and the problem is thoroughly investigated by an expert panel.
There is nil cost to patients who are also provided with their own personal advocate to assist them in filing complaints and in presenting evidence and other details to the investigating board.
At the end of the process the de-identified findings are published and distributed to all clinical areas, particularly hospitals, where all personnel are expected to have regular meetings around the findings to see whether any local application or adjustments are required within their own clinical settings.

The system is thus very useful because it has reduced the stress to affected patients and the global cost has considerably reduced compared to an equivalent process through the legal system.
It also allows adverse event data to enter the formal science database, rather than be sealed under a court order as part of a financial settlement, not allowing the information into the wider evidence database.

This simple process guarantees both justice to a patient, privacy for health providers and and prevention for future patients.

The Danish system offers lessons for policymakers in Australia, where medical harm is not properly reported and managed and is estimated to be widespread with the mechanisms for addressing it often cumbersome and adversarial.

The Danish systems’ primary focus is on helping patients who have been hurt by the health care system.
While the reams of data gathered from claims aren’t used to publicly rate doctors, other health professionals and hospitals, or to systematically search for bad professionals, they can help flag providers who have repeat errors and may pose a risk.

The current system in Australia is characterised by the struggle to get straight answers after a medical error, and to identify accountability.
Financial compensation for additional care, pain, disability or lost work is allowed only for a relative few under the current system.

Medical malpractice lawsuits, the current method for determining liability and compensation effectively shuts out patients when the potential damages are small.
Proving negligence, the usual standard for winning compensation, is difficult.
There are scant incentives for doctors and hospitals (or pharmacists in any community or hospital dispensary) to apologise or reveal details about what happened, or report errors that might unveil a pattern.

I can remember being asked to develop an error reportage system for a regional public hospital, when I was a director of pharmacy within that hospital.
It quickly became obvious that management wanted a system to “blame” the participants in any error process and that it was not going to be de-identified.
I resigned from the multidisciplinary panel as these objectives were beginning to firm up.
I would think that the culture in all public hospitals today remains the same as it always has been, but the Danish system would represent a refreshing alternative.
Norway, Sweden and New Zealand have variations on the Danish program and common to all these programs is a commitment to provide information and compensation to patients regardless of whether or not, negligence is involved.
That lowers the bar of entry for patients and doesn’t pit doctors against them, enabling providers to be open about what happened.

Denmark’s compensation program has been in place since 1992, replacing a lawsuit-based approach..
Today, medical injury claims aren’t handled by the Danish court system but by medical and legal experts who review cases at no charge to patients.
Patients get answers and can participate in the process whether or not they ultimately receive a monetary award.

Filing a claim is free. they can also take the help of attorneys for civil lawsuits. Patients are assigned a caseworker to shepherd them through the process. The hospital or doctor is required to file a detailed response, which patients may rebut.
Patients have access to their complete medical record and a detailed explanation of the medical reviewers’ decisions.
All of this is available for patients and their families through an online portal, which alerts them when there are developments in their claims process.

Compensation is awarded if reviewers determine the care could have been better, or if the patient experienced a rare and severe complication that was “more extensive than the patient should reasonably have to endure.”

Reviewers most often apply one of two criteria the first being the “specialist rule:” How did the treatment compare to care an experienced specialist would provide?

The patient is entitled to compensation if not treated at this level.
A second common criterion is the “fairness rule.”
If the patient experienced a severe medical event that occurs less than 2 percent of the time, he or she is eligible for an award.
An unusual drug reaction or an infection after a knee replacement, are examples.

Patients may file an appeal at no cost if their claim is rejected.
Appeals are reviewed by a seven-member board of doctors, patient representatives, an attorney and two representatives of the Danish health care system.
Patients may request district court review after an unsuccessful appeal, although that happens in only about two percent of claims.

If a patient believes negligence was involved, it can be reported to a parallel system for professional discipline.

Overall, about one in three patients who file a claim is compensated.
The minimum eligible claim is under $2,000, and the average paid out is $30,000, which is usually less costly than a court settlement.

However, it’s estimated that more than seven times as many claims are filed per capita in Denmark, and about four times as many patients per capita receive some award.
A claim for a few thousand dollars would not be worth it in the legal system because of the high cost of pursuing lawsuits.

The Danish health care system helps patients file medical injury claims by providing an independent nurse with legal training to assist at every hospital.
Because physicians don’t have the threat of malpractice hanging over them, they also can be helpful to patients who have been harmed.

The Danish system is not perfect.
Although the data collected from claims is freely shared with researchers, injury and error rates are not published to enable patients to select providers.
By design, there is no communication between the claims and disciplinary systems.
This system has been recommended for introduction into the US health system.
As you might have expected there has been strong resistance from powerful interest groups, mainly trial lawyers.
And one could almost expect drug manufacturing interests to feature as well, hiding behind the cases that have been strong enough so as to not be barred entry to a court hearing, and having any settlement sealed by a court, thus effectively preventing valuable evidence becoming accessible to health professionals.

The Danish system could work well in Australia provided the seven-member board could be protected from contamination from the global pharma industry.
Provisions that safeguard against contamination need to be provided for within the regulations governing the board, including the term of each member’s appointment being a short one.
The system might also reveal the controversial issues surrounding vaccinations for children and seniors if confidence in the system is guaranteed through integrity, and suitable remedies are provided if found faulty.

Because the system potential for reducing malpractice within all health settings, there is also a potential for hospitals and other clinical settings to eliminate mishaps and have the effect of reducing overheads for each setting.
That means also, a potential for private health insurance premiums to reduce to reverse the trend that is currently happening.
This is a long overdue reform that can change a resistant culture for the better.

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