Risk Management _ __________________________________________________________________________
error that harmed the patient [57]. Among the errors that caused harm, 59% caused serious harm and 30% caused death [57]. Another study analyzing paid claims noted that there was a substantial difference in paid claims for diagnostic errors among specialties. The percentage of paid claims for which diagnostic error was alleged was highest among pathology (87%) and radiology (83.9%), and lowest among anesthesiol- ogy (3.5%) and plastic surgery (4.3%) [5]. Although “failure in judgment” is usually a contributing factor for diagnostic errors, most errors involve several con- tributing factors [58; 59; 60]. The origins of diagnostic errors are multifaceted and may involve communication problems, system-related problems (e.g., lack of supervision, workload, technology issues), physician-related factors (e.g., stress, fatigue, hurriedness), patient-related factors, or a combination of any of these [57; 58; 61; 62]. Researchers have narrowed the diag- nostic process down to seven stages, with diagnostic errors occurring in one or more of these stages [62]:
procedure (5%); improper management of treatment course (3%); failure to ensure patient safety (1%), retained foreign body (1%), and wrong or unnecessary treatment or procedure
(1%) [68]. Diagnoses
The leading diagnoses-related allegations have varied somewhat across studies. One analysis of hospital medicine malpractice found that 40% of allegations were failure to diagnose, with the remainder (50%) due to improper procedure and treat- ment issues [69]. Of the diagnosis-related claims, the most common diagnosis was pulmonary embolism with infarction (6%). Factors that contributed to patient injury in these claims included failure to order diagnostic tests; failure to establish a differential diagnosis; failure to appreciate/reconcile relevant signs, symptoms, and test results; insufficient documentation of clinical rationale; and premature discharge [69]. In another study of claims settled between 1985 and 2000, acute myocar- dial infarction was the leading diagnosis (5%), followed by lung, breast, and colon cancer (each accounted for 3% of claims) and appendicitis (2%) [3]. Another study of missed diagnoses in the primary care setting found that more than 35% of missed diagnoses were conditions common in primary care, including pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) [63]. Diagnostic errors are also a predominant source of emergency department allegations (37%) [70]. A 2010 study identified the most common conditions associated with emergency depart- ment claims, with fractures (6%), acute myocardial infarction (5%), and appendicitis (2%) topping the list [70]. In a review of 307 claims of diagnosis error in an ambulatory setting, cancer accounted for 59% of the missed or delayed diagnoses; breast cancer was the leading type of cancer (24%), followed by colorectal cancer (7%), and skin, gynecologic, and hematologic cancers (4% each) [57]. Other diagnoses fre- quently missed or delayed according to that review were infec- tion (5%), myocardial infarction (4%), and fractures (4%) [57]. Patient Motivations Given that a high number of malpractice claims do not involve a medical injury, other factors must motivate patients and families to sue [18; 71]. Patient motivations for malpractice have been extensively studied, and a wide variety of motiva- tions have been identified ( Table 2 ) [18; 58; 71; 72]. In gen- eral, these motivations are not related to financial need but rather to problems with patient-physician communication or the patient-physician relationship and unmet expectations of the patient [71]. The overwhelming majority of patients and families say they just want information about what happened, and many wish to prevent the situation from happening again [18; 71; 73].
• Access and presentation • History taking/collection • Physical exam • Testing • Assessment • Referral • Follow-up
One study in the primary care setting noted that diagnostic process breakdown most frequently occurred during the patient-practitioner clinical encounter (78.9%), which includes errors in history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further work-up (57.4%). Other areas of process breakdown included referrals (19.5%), patient- related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.6%). A total of 43.7% of cases involved more than one of these processes [63]. Medication errors and adverse drug events represent 6.3% of malpractice claims, and the adverse event has been considered to be preventable in approximately 28% to 73% of claims [64; 65; 66]. Most medication errors do not cause adverse events, but when they do, serious harm may be the result; 38% to 46% of adverse drug events were reported to be life-threatening or fatal [64; 65]. A variety of other underlying causes have been identified, including delayed or inappropriate treatment, failure to super- vise or monitor the case, improper performance of procedure, failure/delay in referral, and failure to recognize complications of treatment [2; 3; 58; 67; 68]. In one analysis of 596 closed claims, 364 (67%) were diagnosis-related events [68]. Other allegations were related to improper inspection/maintenance of equipment (13%); improper performance of treatment or
78
MDAZ2326
Powered by FlippingBook