National Study Highlights the Magnitude of Clinical Documentation Errors on Malpractice Risk

Boston, MA—November 18, 2024—Candello, a division of CRICO, releases its latest benchmarking report, titled “For the Record: The Effect of Documentation on Defensibility and Patient Safety.” The report provides an in-depth look at one of the most persistent challenges providers face in health care delivery: documentation.

This report reveals trends and insights pertaining to clinical documentation using the Candello database, which contains approximately one-third of all medical malpractice claims in the U.S. The Candello data collaborative includes health systems such as the University of California Health and Mass General Brigham. Through a ten-year retrospective analysis, the findings highlight how documentation influences malpractice case outcomes in high-risk clinical specialties, consider the role of emerging technology, and offer providers actionable recommendations they can adopt to safeguard their practice and support patient safety.

“This report underscores the need for precision in health care documentation as a vital defense against malpractice claims,” says Vice President of Candello, Michael Paskavitz, “Our data illuminate how a documentation error can make a case go from unlikely to likely to close with an indemnity payment.”

Candello’s focus on documentation reflects evidence of how unsound documentation practices can affect legal outcomes. Based on an analysis of more than 65,000 medical malpractice cases closed between 2014–2023, several key takeaways were shared in “For the Record”:

• 20% of medical malpractice cases involve at least one documentation failure.
• Documentation issues more than double the odds that a case will close with an indemnity payment.
• Common documentation errors that significantly increase payment odds include alterations to the medical record, insufficient documentation of clinical findings, rationale, and informed consent.
• Documentation errors are most prevalent in surgery, medicine (multiple specialties), and nursing services, with considerable risk also seen in obstetrics and gynecology, anesthesiology, and emergency medicine services.

Request the Report

Candello encourages health care providers, risk managers, and industry leaders to use this resource to support safer, more defensible documentation practices and to sharing this link with their providers.

About CRICO and Candello

The CRICO insurance program insures all of the Harvard medical institutions and their affiliates, providing coverage to 34 hospitals, 17,500 physicians, more than 325 other health care organizations, and in excess of 130,000 other clinicians and employees. For close to 50 years, CRICO has provided industry-leading medical professional liability coverage, claims management, and patient safety resources to its subscribers, and is a recognized leader in evidence-based risk management. Learn more about CRICO.

Candello is a division of CRICO. Through national partnerships, Candello pools malpractice data and expertise from captive and commercial professional liability insurers across the country to provide clinical risk intelligence products and solutions. The data represent one-third of U.S. MPL cases and include open and closed cases as well as cases with and without indemnity payments. An active online community facilitates peer discussion and fosters shared learning, while web-based tools employ Candello’s clinical coding taxonomy to connect the dots from medical error to patient safety interventions. Learn more about Candello.