About 10% of ED malpractice claims involve medication errors, according to a recent report.1
A careful analysis of the claims and their contributing factors “tells you a story about these ED cases,” says Penny Greenberg, MS, RN, CPPS, editor of the report. Greenberg is senior program director of patient safety services for CRICO Strategies, which provides medical professional liability coverage for the Harvard medical community. Of 1,629 cases with emergency medicine as the primary responsible service, 155 involved medication errors.
The report is a product of CRICO Strategies’ national Comparative Benchmarking System, the largest malpractice claims database with detailed coding in the world. The database contains nearly 400,000 medical malpractice cases from more than 20 insurers and more than 400 healthcare entities, comprising about 30% of all paid and unpaid malpractice cases in the United States. Cases are coded by allegation, severity, responsible services, initial and final diagnosis, clinical setting of the event, contributing factors, and human factors.
“When you have an event in the ED, most organizations conduct a cause analysis and develop an action plan. You think you have fixed the problem and a year later, a similar event happens again,” Greenberg notes. The database allows for an analysis of many cases, and reveals the contributing factors and trends driving similar events.
The authors of the report examined closed cases involving a medication-related problem occurring from 2005-2014. Of the 351 closed cases that occurred in the ED setting, 38% closed with payment, with an average indemnity of about $230,000.
The analysis of the claims revealed that the top three risk factors for medication-related problems in the ED involved the EP’s clinical judgment, selection and management of medications, and patient assessment. “These are the things to focus on when implementing patient safety initiatives,” Greenberg adds. Some other findings about the medication-related ED cases:
- Fifty-two percent involved patient assessment.
“This should prompt EDs to question, ‘Do we have a structured way to assess patients and communicate findings between providers? Are we moving too quickly?’” Greenberg says.
Of the cases with patient assessment as a contributing factor, 30% involved the history and physical. “Lack of a complete history and physical can affect the identification of a differential diagnosis and treatment plan,” Greenberg says.
One case involved a stroke patient who received tPA despite registering a systolic blood pressure of 197 (the drug is contraindicated if the patient’s systolic blood pressure is above 185). The patient suffered a hemorrhagic stroke, and the family successfully sued the EP. The case settled for $200,000.
“Lack of assessment and communication between providers regarding the patient’s blood pressure and contraindications of tPA contributed to this event,” Greenberg concludes.
Assessment and ordering issues “go hand in hand,” she adds. “If the patient assessment is not complete and accurate, it can affect decision-making and the treatment plan.”
- Communication was a factor in 39% of the cases.
“This is not surprising in ED cases,” Greenberg says. Sixty-four percent of the cases with communication as a contributing factor featured a provider-to-provider communication issue. For 51% of this group of cases, the communication issue was between a provider and the patient or family member.
- Sixty-seven percent of cases involved ordering of medications.
Here are some actual malpractice cases included in the analysis:
A 32-year-old woman came to the ED complaining of slurred speech, along with numbness and tingling in her jaw and upper extremities. She reported starting methadone therapy recently, along with a history of chronic back pain and long-term use of opioid narcotics.
The patient was diagnosed with peripheral neuropathy and received a muscle relaxant. The patient was advised to take ibuprofen and to discontinue the other muscle relaxant she was taking.
“She was discharged, and died at home the next day,” Greenberg says. The patient’s family sued the EP for failure to diagnose methadone toxicity.
Vague discharge discussions complicated the defense of the claim. The instructions didn’t tell the patient to discontinue the other muscle relaxant. “It just said, ‘Take medications as directed,’” Greenberg notes. “It would have been helpful if the discharge instructions had been more specific.” The case was eventually dismissed, but only after the EP paid $8,000 in legal expenses.
A woman with a history of recent head trauma presented to the ED with chest pain, and was diagnosed with an acute myocardial infarction.
“The EP’s documentation noted she had been admitted 11 days earlier after falling at home and sustaining a head trauma that resulted in a laceration to the forehead,” Greenberg says. The patient received nitroglycerin and morphine. The EP consulted a cardiologist, but failed to communicate the patient’s history of recent head trauma during the discussion.
The cardiologist recommended metoprolol and tenecteplase, a thrombolytic medication that is contraindicated in patients with recent trauma because of increased risk of bleeding. The hospital’s policy listed head injury within the previous three months as a contraindication for tenecteplase.
The patient was started on the medication, and a cardiac catheterization was performed. After the procedure, a change in mental status was noted, and a neurologist was consulted. On exam, the patient’s pupils were fixed and nonreactive, and the patient was intubated.
A CT scan of the head showed a massive subarachnoid bleeding. “The family decided to provide comfort care for the patient, and the autopsy listed the cause of death as subarachnoid bleed due to thrombolytic therapy,” Greenberg notes. “The case settled for $80,000.”
An 84-year-old woman presented to the ED with symptoms of urinary tract infection. The patient reported a previous allergic reaction to ciprofloxacin. “The ED resident ordered [nitrofurantoin] after discussion with the attending,” Greenberg explains. The patient was discharged to the assisted living facility.
Four days later, she was transported to the ED with severe back pain, and diagnosed with urosepsis and hyperkalemia. “The patient suffered acute delirium, pyelonephritis, urinary retention, and chronic back pain,” Greenberg says.
After researching the patient’s medication list during the second ED visit, the ED director established that nitrofurantoin was not appropriate for elderly females with urinary tract infection.
“Additionally, on review, it was noted that a kidney panel should have been done prior to ordering the drug,” Greenberg says. “The case settled for $16,000.”
- CRICO Strategies. Medication-related malpractice risks: CRICO 2016 CBS Benchmarking Report. Boston; May 27, 2017.
- Penny Greenberg, MS, RN, CPPS, Senior Program Director for Patient Safety Services, CRICO Strategies, Boston. Phone: (617) 450-6850. Fax: (617) 450-8296. Email: PGreenberg@rmf.harvard.edu.