Misdiagnosis is the most common reason for malpactice claims in primary care practices
Primary care ambulatory claims appear more difficult to defend compared with other settings
Failure to diagnose or delayed diagnosis are the most common allegations in malpractice claims involving primary care practices, according to an analysis of 7,224 closed malpractice claims of two medical liability insurers in Massachusetts between 2005 and 2009.1
Researchers identified 551 claims arising from primary care practices. Of these cases, 72.1% were related to diagnosis. Cancer, heart disease, blood vessel diseases, and infections topped the list of diagnoses.
"We were surprised at the extent to which diagnoses errors dominated the cases," says Gordon Schiff, MD, the study’s lead author and associate director of the Center for Patient Safety Research and Practice at Harvard Medical School in Boston.
The researchers also expected to find more cases of "dropped balls" with abnormal test follow-up, such as failing to follow up on an abnormal pulmonary nodule or elevated prostate specific antigen, Schiff says. "While there were a significant number of cases such as this, we are surprised that these represented only a minority of malpractice suits related to cancers," he says.
The study points to a need to tighten up systems for evaluation, follow-up, and documentation and referral management, according to Schiff. "It also means that if we are going to prevent malpractice suits, we have to prevent malpractice in the first place. There is no getting around it," he says.
More difficult to defend
Primary care ambulatory claims appear more difficult to defend compared with other settings, based on the study’s findings. While primary care practices account for fewer than one in 10 malpractice cases, those cases were far more likely to be either or lost in a jury trial, compared with nongeneral medical claims.
Urmimala Sarkar, MD, MPH, assistant professor of medicine in residence in the Division of Internal Medicine at University of California, San Francisco, says, "In the hospital, patients are under constant observation. Documentation is voluminous. In contrast, 15-minute ambulatory visits are often sparsely documented. This introduces significant ambiguity."
In a 2012 study that surveyed 848 primary care physicians, a variety of reasons for diagnostic difficulties were reported.2 Half of the physicians reported that more than 5% of their patients were difficult to diagnose, and inadequate knowledge was the most commonly reported cognitive factor. "I think the fact that we asked folks about cognitive barriers to diagnosis and they responded with a lot of concerns about health systems reflects the multi-level challenges of making timely and accurate diagnoses in the outpatient setting," says Sarkar.
Another issue contributing to primary care claims is that longer time-frames involved with the ambulatory diagnosis process lend themselves to the label of "delayed" diagnosis, says Sarkar. An important strategy in reducing "delayed diagnosis" claims is "emphasizing the importance of timely follow-up and adherence to diagnostic testing, and documenting this discussion," she says.
Patient contributions to delays in diagnosis are present in many successful malpractice claims, such as when patient-plaintiffs failed to obtain a follow-up visit or recommended test, notes Sarkar. In these cases, patients often claim that they didn’t realize the importance of following up.
"Explicit documentation of the need for follow-up — a written notification about the diagnostic work-up and its importance — is helpful," says Sarkar.
- Schiff GD, Puopolo AL, Huben-Kearney A, et al. Primary care closed claims experience of Massachusetts malpractice insurers. JAMA Intern Med Published online Sept. 30, 2013; doi:10.1001/jamainternmed.2013.11070.
- Sarkar U, Bonacum D, Strull W, et al. Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians. BMJ Qual Saf 2012; 21(8):641-648.
- Gordon Schiff, MD, Associate Director, Center for Patient Safety Research and Practice, Harvard Medical School, Boston. Phone: (617) 732-4814. Fax: (617) 732-7072. Email: firstname.lastname@example.org.
- Urmimala Sarkar, MD, MPH, Assistant Professor of Medicine in Residence, Division of Internal Medicine, University of California, San Francisco. Phone: (415) 206-8494. Email: email@example.com. F