The frequency of malpractice claims is associated with higher rates of hospital admission for ED patients with lower-risk syncope, according to the results of a recent study.1

“There are many factors driving the decision to admit. Our goal here was to determine what effect malpractice climate may have,” says James Quinn, MD, the study’s lead author and professor of emergency medicine at Stanford University Medical Center. For example, patients with vagal symptoms, no history of cardiac disease, and a normal ECG would be low-risk patients, as determined by several of the syncope rules and risk scores available.2-4

Quinn and colleagues analyzed data from the Clinformatics Data Mart database on ED visits. They found 1.3% of ED visits between 2008 and 2017 were associated with syncope. Of those, 45% met criteria for lower-risk syncope. In this lower-risk group, 18.8% were admitted.

The authors also studied the rate of physician malpractice claims in the National Practitioner Data Bank during the same period. If the number of malpractice claims was higher, hospital admissions rates also were higher.

These findings suggest defensive medicine is the likely reason for the extra admissions. “The malpractice climate should not be as great a determining factor when deciding the ED disposition of low-risk patients,” Quinn argues.

This raises the question of why some low-risk patients are admitted when they really do not need to be. Generally, EPs know who the low-risk patients are. For the most part, these patients do not require admission.

The issue is EPs might hesitate to discharge these low-risk patients, fearing a possible bad outcome and lawsuit alleging delayed diagnosis or premature discharge. “With decision rules and support, [EPs] should be more comfortable discharging these patients,” Quinn says.

Documenting the patient’s low-risk characteristics and using a risk score is helpful to the defense. From 2008 to 2017, there was an overall downward trend in the admission rate of low-risk patients.1 “But there is still a good portion who are admitted,” Quinn notes. “A thorough assessment and good judgment, supported by guidelines, can improve the management and efficiency of these patients.” 


  1. Quinn J, Chung S, Murchland A, et al. Association between US physician malpractice claims rates and hospital admission rates among patients with lower-risk syncope. JAMA Netw Open 2020;3:e2025860.
  2. Quinn J, McDermott D, Stiell I, et al. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med 2006;47:448-454.
  3. Probst MA, Gibson T, Weiss RE, et al. Risk stratification of older adults who present to the emergency department with syncope: The FAINT score. Ann Emerg Med 2020;75:147-158.
  4. Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. Circulation 2017;136:e60-e122.