EPs were named in 18% of malpractice cases involving pulmonary embolism (PE) and deep vein thrombosis (DVT), according to the authors of a recent analysis.1

Some common allegations in 277 cases from 1987 to 2018:

  • Failure to diagnose and treat (62% of cases);
  • Failure to prescribe anticoagulation when the patient is discharged (8% of cases);
  • Premature discontinuation of anticoagulation (2% of cases).

Researchers were surprised to see so many nonsurgeons, including EPs, among the named defendants. “The reasons the lawsuits were brought seemed to be very simple things that could be easily addressed,” says Issam Koleilat, MD, one of the study’s authors and a vascular surgeon at Montefiore Medical Center in Bronx, NY. Common issues included lack of adequate administration of prophylaxis or medications to prevent blood clots. Koleilat says this documentation is helpful to the defense:

  • the reasons for treatment with anticoagulation when it is needed (or reasons why it cannot be given);
  • the intended duration of anticoagulants, especially in cases where prolonged administration (such as after some orthopedic or cancer surgeries) is recommended;
  • the EP’s thought process.

“This can help with transition and continuity of care, and can also potentially serve to protect someone legally,” Koleilat says.

For example, EPs could document: “Peroneal DVT with high risk for anticoagulation. Plan to repeat duplex in two weeks and reassess need for anticoagulation.”

Missed diagnosis is the most common reason for ED malpractice lawsuits involving PE/DVT, according to Jay M. Brenner, MD, FACEP, medical director of SUNY Upstate University Medical Campus ED. In one malpractice case, the DVT was diagnosed properly, but the EP missed tachycardia suggestive of a PE. “In this case, the patient was discharged, which was a disposition error,” Brenner says. The tachycardia probably was representative of right heart strain and impending cardiac arrest from obstructive shock, he explains.

The patient did not meet criteria for outpatient PE treatment, based on Hestia criteria, a tool that identifies low-risk PE patients. The criteria require the patient to be hemodynamically stable, with no need for thrombolysis or embolectomy, no active bleeding, and not at high risk for bleeding.

The patient must not need oxygen to keep oximetry over 90% and not receive anticoagulation prior to PE diagnosis. The patient’s creatinine level should not be over 30. Also, the patient should present with no severe liver impairment, no pregnancy, no history of heparin-induced thrombocytopenia, and no medical or social reason for admission.

“Hestia criteria is well-validated. A patient who does not meet Hestia criteria should be admitted,” Brenner suggests. For EPs, says Brenner, “the most important factor in these lawsuits is to document your medical decision-making.”

One piece of documentation in particular helps to defend malpractice claims: The EP obtained a Pulmonary Embolism Rule-out Criteria or Wells risk stratification score, according to Brenner. The score, noted in the chart, can justify why the EP did (or did not) obtain a D-dimer level to rule out venous thromboembolism (VTE), an ultrasound to rule out a DVT, or pulmonary vascular imaging (such as a CT or ventilation/perfusion ratio) to rule out a PE. “It is also important to be accurate about the knowledge base surrounding VTE if you are deposed,” Brenner offers.

The EP defendant can expect to be grilled on whether the patient met Wells criteria and/or Hestia criteria. “It usually is safe to discharge patients home with a DVT, unless they require thrombolysis or have some other medical or social reason for admission,” Brenner says.

However, patients with PE require more thoughtful consideration. “The Hestia criteria has been shown to be highly effective at identifying patients with PE for whom discharge to home is safe and acceptable,” Brenner reports.2


  1. Wilson E, Phair J, Carnevale M, Koleilat I. Common reasons for malpractice lawsuits involving pulmonary embolism and deep vein thrombosis. J Surg Res 2020;245:212-216.
  2. Weeda ER, Kohn CG, Peacock WF. External validation of the Hestia criteria for identifying acute pulmonary embolism patients at low risk of early mortality. Clin Appl Thromb Hemost 2017;23:769-774.