Cardiology-Related Misdiagnoses Frequently Alleged in ED Malpractice Claims
Malpractice claims naming emergency physicians (EPs) differ from claims involving other specialties in many ways, according to an analysis.1 “We were able to compare claims to highlight the differences among the specialties,” says Laura C. Myers, MD, MPH, CPPS, the study’s lead author.
Myers and colleagues analyzed closed claims from 2007 to 2016 from CRICO Strategies’ Comparative Benchmarking System database. Of 54,772 claims analyzed, 2,760 involved EPs, 5,886 involved internists, and 3,207 involved surgeons.
“We wanted to provide an updated look at malpractice risk for EPs,” says Myers, who conducted the study as a Harvard quality/safety fellow at Massachusetts General Hospital and currently is a research scientist at Kaiser Permanente Northern California.
As a group, the researchers brought to the table a great deal of expertise in patient safety and quality improvement. “We understand the huge opportunity that exists to improve patient care by understanding the insights that live in malpractice data,” says Emily L. Aaronson, MD, MPH, another study author and assistant chief quality officer at Massachusetts General Hospital. Aaronson also is an assistant professor of emergency medicine at Harvard Medical School. “In emergency medicine, very little had been done to glean the insights from this data,” she adds.
One group of researchers had tried, but their work was more than a decade old.2 Other investigators had looked at narrow disease-oriented data sets.3,4 “We knew there was more to learn, and we had the data to learn from it,” Aaronson says.
The frequency of emergency medicine claims increased steadily over the 10-year period. “We were surprised to see just how much the frequency of claims and indemnity payments had increased,” Aaronson offers. These are some important findings:
• Most claims (58%) against EPs resulted from misdiagnosis. Misdiagnosis is “the biggest driver of claims and settlements in ED litigation,” Aaronson notes. “This is incredibly important from a patient safety and risk mitigation perspective.”
The findings confirm the need for focused attention on misdiagnosis in the ED. “No emergency medicine society has explicitly carved out strategies aimed at this in the same way they have for stroke or STEMI or sepsis,” Aaronson adds.
• Diagnosis-related allegations were more common in emergency medicine-related claims (58% of claims) than in claims involving internists (42% of claims). “Internists have the opportunity to follow patients longitudinally, as opposed to having to make quick, triage-based decisions,” Myers says.
• The most common final diagnoses were myocardial infarction, pulmonary embolus, and cardiac arrest. “These are diagnoses that are well-known to emergency medicine providers,” Myers observes.
Failure to obtain consultations with on-call specialists was a factor in some claims. “Engaging with medicine subspecialists in cardiology and pulmonology may help to affirm diagnoses made by emergency medicine providers,” Myers suggests.
It is unclear if the missed diagnoses happened because of uncommon presentations, high comorbidity burden that complicated the diagnosis, provider fatigue, provider bias, or poor access to advanced diagnostic testing.
“Further investigation should try to dissect the factors associated specifically with diagnosis-related claims,” Myers says.
• Acute myocardial infarctions (MIs) made up only 2% of all claims. “This is an area that many ED providers carry around fear about,” Aaronson reports.
Some ED providers, keenly aware of the malpractice risk posed by misdiagnosis of MI, made practice changes to improve care of suspected MI patients.
“It’s also possible that other safety improvements and more sophisticated diagnostics have made this less treacherous territory, and that the fear is, in fact, not as well-founded as we think,” Aaronson says.
• EP defendants’ median age (44 years) was younger vs. internists (52 years) and general surgeons (51 years).
• Claims involving EPs were filed in a median time of 15 months vs. internists (18 months) and surgeons (16 months).
• For claims naming EPs, the median open claim time was longer (23 months) vs. claims naming internists (20 months) and claims naming surgeons (22 months).
• Most (72%) claims naming EPs also included the hospital as a co-defendant. In contrast, ED nurses rarely were included (only 4% of the time).
“Nurses are often not named as individuals on claims; rather, the institution is named,” Myers explains.
• Procedural complications were involved in one-quarter of claims involving EPs.
The most common procedures involved in the malpractice lawsuits were intubation, suturing, and lumbar puncture. Procedural competency already is addressed heavily in emergency medicine training. “But it’s possible that alternative approaches to teaching these skills may further reduce the likelihood of claims,” Myers offers. Procedure-related claims were associated with increased likelihood of a payment compared to other malpractice claims. Simulation could decrease the risks of procedure-related claims.
“Many programs across the country have simulation centers, and staff trained to run scenarios with learners,” Myers says.
More safeguards are needed to protect patients from poor outcomes and ED providers from litigation related to procedures. “This may be related to training, supervision, assessments of ongoing competency, or to shared decision-making around the consent process itself,” Aaronson says.
REFERENCES
- Myers LC, Einbinder J, Camargo CA Jr, Aaronson EL. Characteristics of medical malpractice claims involving emergency medicine physicians. J Healthc Risk Manag 2020; Oct 19. doi: 10.1002/jhrm.21450. [Online ahead of print].
- Brown TW, McCarthy ML, Kelen GD, Levy F. An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers. Acad Emerg Med 2010;17:553-560.
- Ferguson B, Geralds J, Petrey J, Huecker M. Malpractice in emergency medicine — a review of risk and mitigation practices for the emergency medicine provider. J Emerg Med 2018;55:659-665.
- Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: A study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007;49:196-205.
In an analysis, 58% of claims against emergency physicians resulted from misdiagnosis. Diagnosis-related allegations were more common in emergency medicine-related claims (58% of claims) than in claims involving internists (42% of claims). The most common final diagnoses were myocardial infarction, pulmonary embolus, and cardiac arrest.
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