United States General Accounting Office

GAO 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

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

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,

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.

Page 1 GAO/HEHS-96-24 VA Health Care Malpractice Claims
B-266073 

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.

Results in Brief 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 VA operates 158 medical centers and employs approximately 10,723 fulland 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

3

VAMCs visited were as follows: Martinsburg, West Virginia; Cleveland, Ohio; Houston, Texas;

Hines-Chicago, Illinois; St. Louis, Missouri; and Fayetteville, North Carolina.

Page 2 GAO/HEHS-96-24 VA Health Care Malpractice Claims
B-266073 

provisions of the Federal Tort Claims Act4 (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

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.

Page 3 GAO/HEHS-96-24 VA Health Care Malpractice Claims
B-266073 

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.

Malpractice Claims

Made Against VA Are

Increasing

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

Fiscal year

Claims

filed

Claims

denieda

Claims

settledb

Amount

paid

1990 678 304 168 $9,854,744

1991 672 346 152 9,868,960

1992 749 383 183 13,284,344

1993 801 406 188 16,640,350

1994 978 667 252 19,640,022

Total 3,878 2,106 943 $69,288,420

aClaims denied and closed without payment.

bA 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

Page 4 GAO/HEHS-96-24 VA Health Care Malpractice Claims
B-266073 

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

Fiscal year Suits filed

Suits settled Judgments

Number

Amount

paid Number

Amount

paid

1990 248 179 $20,090,593 6 $1,872,045

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 $111,133,966 67 $24,911,791

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:

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.

Page 5 GAO/HEHS-96-24 VA Health Care Malpractice Claims
B-266073 

• 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

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.

Page 6 GAO/HEHS-96-24 VA Health Care Malpractice Claims
B-266073 

Data on Malpractice

Cases Are Not

Consistently Used in

VAMC Quality

Assurance or Risk

Management

Programs

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

Page 7 GAO/HEHS-96-24 VA Health Care Malpractice Claims
B-266073 

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

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 Numbers in percent

Allegation VA Army Navy Air Forcea

Diagnosis related 26 41 42 37

Treatment related 31 15 7 40

Wrongful death b b b 16c

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.

aThe 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.

bData not provided for these categories.

cNot otherwise classified.

Appendix II shows the elements within six types of malpractice claim

allegations in table 3.

Page 8 GAO/HEHS-96-24 VA Health Care Malpractice Claims
B-266073 

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.

Conclusions 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

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.

10Although 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.

Page 9 GAO/HEHS-96-24 VA Health Care Malpractice Claims
B-266073 

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 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 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.

Page 10 GAO/HEHS-96-24 VA Health Care Malpractice Claims
B-266073 

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

Page 11 GAO/HEHS-96-24 VA Health Care Malpractice Claims
Contents

Letter 1

Appendix I 

DOD Tort Claim

Experience by Service

Branch, Fiscal Years

1990-94

14

Appendix II 

Malpractice Claims

Description Codes

15

Tables Table 1: VA’s Administrative Claim Experience, Fiscal Years

1990-94

4

Table 2: VA’s Lawsuit Experience, Fiscal Years 1990-94 5

Table 3: Major Negligence Allegations, by Percentage of Claims

Filed

8

Table I.1: U.S. Army Claim Experience 14

Table I.2: U.S. Navy Claim Experience 14

Table I.3: U.S. Air Force Claim Experience 14

Abbreviations

AFIP Armed Forces Institute of Pathology

DOD Department of Defense

VA Department of Veterans Affairs

VAMC Veteran’s Affairs Medical Center

Page 12 GAO/HEHS-96-24 VA Health Care Malpractice Claims
Page 13 GAO/HEHS-96-24 VA Health Care Malpractice Claims
Appendix I 

DOD Tort Claim Experience by Service

Branch, Fiscal Years 1990-94

Table I.1: U.S. Army Claim Experience

Fiscal year Claims filed

Claims

denied

Appeals

denied Claims paid Amount paid Suits filed Suits 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 year

Claims

filed Judgments Amount paid Dismissals Suits settled Amount paid

Suits

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 year Claims filed

Administrative

claims settled Amount paid Suits filed Suits 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 $43,455,725 938 420 $108,690,591

aU.S. Army Litigation Division provided only 5-year aggregate information for these categories.

Page 14 GAO/HEHS-96-24 VA Health Care Malpractice Claims
Appendix II 

Malpractice Claims Description Codes

Code number Description

Diagnosis related

010

020

030

040

050

060

Failure to diagnose (that is, concluding that patient has no

disease or condition worthy of further follow-up or observation)

Wrong diagnosis or misdiagnosis (that is, original diagnosis is

incorrect)

Improper performance of test

Unnecessary diagnostic test

Delay in diagnosis

Failure to obtain consent/lack of informed consent

Surgery related

210

220

230

240

250

260

270

280

285

Failure to perform surgery

Improper positioning

Retained foreign body

Wrong body part

Improper performance of surgery

Unnecessary surgery

Delay in surgery

Improper management of surgical patient

Failure to obtain consent/lack of informed consent

Medication related

305

310

315

320

325

330

340

350

355

360

365

370

380

Failure to order appropriate medication

Wrong medication ordered

Wrong dosage ordered of correct medication

Failure to instruct on medication

Improper management of medication regimen

Failure to obtain consent/lack of informed consent

Medication error

Failure to medicate

Wrong medication administered

Wrong dosage administered

Wrong patient

Wrong route

Improper technique

Obstetrics related

505

510

520

525

540

550

555

560

570

575

580

Failure to manage pregnancy

Improper choice of delivery method

Improperly performed vaginal delivery

Improperly performed C-section Failure to obtain consent/lack of

informed consent

Improperly managed labor

Failure to identify/treat fetal distress

Delay in treatment of fetal distress (that is, identified but treated in

untimely manner)

Retained foreign body/vaginal/uterine

Abandonment

Wrongful life/birth

(continued)

Page 15 GAO/HEHS-96-24 VA Health Care Malpractice Claims
Appendix II 

Malpractice Claims Description Codes

Code number Description

Treatment related

610

620

630

640

650

660

665

670

675

680

685

Failure to treat

Wrong treatment/procedure performed (also improper choice of

treatment or procedure)

Failure to instruct patient on self care

Improper performance of a treatment or procedure

Improper management of course of treatment

Unnecessary treatment

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

720

730

Failure to monitor

Failure to respond to patient

Failure to report on patient condition

Source: Adopted from the Harvard Risk Management Foundation Allegations of Negligence by

the National Practitioner Data Bank.

(101472) Page 16 GAO/HEHS-96-24 VA Health Care Malpractice Claims
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Permit No. G100