Diagnosis-related events are the single largest root cause of medical professional liability claims, according to a recent analysis from Coverys, a medical malpractice insurer based in Boston. They account for 33% of medical professional liability claims and 47% of indemnity payments, the report says.

Coverys analyzed more than 10,500 closed medical liability claims from 2013 to 2017 to determine the root causes of diagnosis-related allegations. The analysis determined that testing is involved in more than half of all diagnosis-related malpractice claims. Testing issues, including failures in ordering, performing, receiving/transmitting, and interpreting test results, account for more than 50% of diagnosis-related claims.

Adverse events involving cancer were most prevalent, followed by infection, cardiac/vascular conditions, fracture/dislocation, and myocardial infarction.

Most diagnostic errors occur in outpatient settings, according to the report, with 24% of diagnosis-related claims taking place in the ED and urgent care facilities, but 35% of diagnostic errors occur in non-ED outpatient settings, such as physicians’ offices or clinics. (The full report is available online at: https://bit.ly/2qlmVtz.)

The missed or delayed cancer diagnoses are largely acts of omission, which makes the claim particularly difficult to defend, notes Robert Hanscom, JD, vice president of business analytics with Coverys.

“They didn’t make the diagnoses, so they don’t even know anything is wrong until weeks or months later when they are served with a lawsuit. By then they don’t remember the case well, if at all, and they don’t know what the circumstances were or why they may not have made that diagnosis at that point,” Hanscom says. “Despite all the systems we put in place for monitoring care and documenting what happens with a patient, there is a dearth of information about these missed or delayed cancer diagnoses.”

The claims analysis shows the risk of physicians yielding to the pressure of a heavy workload by rushing the decision-making process, Hanscom says. Physicians must take the time to consider all the possibilities.

“We want providers to not get caught in traps where they shortcut the diagnostic process from the cognitive side. We know that time is very limited and everything is frenzied for the physicians, but they still need to be getting differential diagnoses,” Hanscom says. “Even if they’re pretty sure of a diagnosis, they need to always be asking what else could this be. In many of these cases, we see a narrow diagnostic focus in which they home in on what they think this is, and that becomes fact.”

Even the best physicians can be derailed by poor processes, Hanscom says, such as an electronic medical record not showing the patient’s entire history. Failure to follow up on test results also can result in inaccurate diagnoses, and patient referrals to other specialists may get lost in the system, he says.

Diagnosis errors are cropping up more in outpatient settings partly because more care is being provided on an outpatient basis, but Hanscom says there is more going on than simply a proportional increase in claims. Outpatient settings tend to have fewer risk management resources available, and that results in more claims, he says.

Radiology poses a challenge because there can be variability in how they read tests, Hanscom says. Providers should take steps to reduce that variability as much as possible, he says.

“Radiologists tend to write lengthy reports that are sometimes not clear. They may say there is something that looks kind of suspicious and should be followed up, but it’s buried in there at paragraph four of page two,” he says. “For the primary care physician to find that and figure out he should do something, that can be a real challenge. Radiology has put it in the report so they think they’re covered, but if the physician doesn’t recognize that something should be done, they both get named in the lawsuit. The plaintiff’s attorney doesn’t make a distinction over who is more responsible for the communication failure.”