Risk Management _ __________________________________________________________________________
Studies of malpractice claims have provided valuable infor- mation on the most common underlying causes of alleged injuries/events (also known as “medical misadventures”) and the diagnoses at highest risk for malpractice. Additional studies have identified a wide variety of factors that motivate individuals to file a malpractice claim. Understanding the risk factors and patient motivators for malpractice can help physicians develop risk management strategies that address the most common issues related to patient safety. Underlying Causes Diagnostic error (misdiagnosis or missed or delayed diagnosis) is the most common allegation in malpractice claims, noted in 22% to 78% of all claims [2; 3; 5; 16; 55; 56]. In a study of 307 claims alleging diagnostic error in the ambulatory setting, researchers found that 59% of the claims involved a diagnostic 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]:
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 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].
• 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].
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PAPA2126
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