ED Providers Are Frequent Defendants in Aortic Pathology Malpractice Claims
When a group of vascular surgeons analyzed malpractice claims involving aortic pathology, they found emergency medicine was the most commonly named specialty. Researchers identified 196 cases involving aortic aneurysms and 150 cases involving aortic dissections in the Westlaw database from 1987-2019.1
“We were looking at the cases from a surgical perspective. We were focused on postoperative complications,” says Krystina Choinski, MD, the study’s lead author and a resident in the division of vascular surgery at the Icahn School of Medicine at Mount Sinai in New York.
In fact, postoperative complications were involved in just 10% of the malpractice claims. “The big claim that stood out was failure to diagnose and treat,” Choinski observes.
That allegation was included in 61% of claims. Delayed diagnosis and treatment also was a frequent allegation (21% of claims). Both allegations directly involve the ED. “The ED is the front line, the people who are talking to these patients and getting the diagnosis. The really big thing, since there is such high morbidity and mortality, is getting the right diagnosis in the first place,” Choinski explains.
EPs were defendants in 29% of claims. Other specialties were named less frequently (20% for cardiology, 14% for internal medicine, 11% for radiology, 10% for cardiothoracic, and 10% for vascular surgery).
Most (63%) patients with aneurysms presented with abdominal pain, and 37% presented with back pain. Most (78%) patients with dissections presented with chest pain. Patients were misdiagnosed with gastrointestinal conditions in 12% of cases, with cardiovascular conditions in 9% of cases, and shortness of breath in 14% of cases.
Many (83%) cases were wrongful death lawsuits. In 53% of cases, juries ruled in favor of the defendant. Juries ruled in favor of the plaintiff in 25% of cases. The rest resulted in a settlement. Notably, EPs were more likely to be named in malpractice cases than the surgical intervention team. “That shows that the initial task of getting the diagnosis is everything — to avoid patient injury and, ultimately, to avoid litigation,” Choinski says.
This finding spotlights the importance of improving diagnostic accuracy in the ED. “We see litigation as a way of representing patient complications and injuries, because complications and injuries result in patients bringing cases to court,” Choinski explains. “We wanted to try to use that information to see how medical practice could be improved to hopefully prevent these injuries.”
Many ED patients complain of nonspecific abdominal pain. “But in the right patient population, for patients where there are red flags, the threshold for getting imaging and for calling vascular should be lower,” Choinski advises.
Even in lower-risk patients, “it can never hurt to think about it, and add it on to the differential,” Choinski offers. “When in doubt, get the scan. It requires IV contrast, but we really think it’s worth it in terms of having an accurate diagnosis and, if necessary, prompt treatment.”
In missed aortic dissection malpractice cases, some patients had been worked up in the ED for chest pain but in fact had an aortic dissection. For other younger patients, there was a history of substance abuse but no other risk factors. “With aortic dissection, there’s an immediate need for blood pressure control to prevent the dissection from extending further,” Choinski notes.
The vascular team will determine if the patient needs to go to the OR right away or if the patient can be monitored in the ICU.
“An additional team the ED can contact, in addition to the vascular team, is the ICU, because these patients are going to need to be put on drips for blood pressure,” Choinski says. Recently, an ED patient with abdominal pain reported a previous abdominal aortic aneurysm (AAA). “The ED did an excellent job of calling us immediately, before the imaging even came up,” Choinski reports.
Fortunately, staff were watching the patient closely and noticed right away the patient had become clammy and pale, and was hypotensive. The AAA had ruptured. That patient was taken immediately to the OR, and survived. “In that case, every moment mattered. Everything worked,” Choinski says.
REFERENCE
- Choinski K, Sanon O, Tadros R, et al. Review of malpractice lawsuits in the diagnosis and management of aortic aneurysms and aortic dissections. Vasc Endovascular Surg 2022;56:33-39.
Making the diagnosis is everything — to avoid patient injury and, ultimately, to avoid litigation.
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