Two research papers released in the past several weeks both point to the significance of diagnostic errors as a source of medical malpractice claims.
A peer-reviewed paper published in Diagnosis on July 11 found that inaccurate or delayed diagnoses were cited in 34% of medical malpractice claims where the patient died or was seriously disabled. In 65% of those claims, the diagnosis error led to death or permanent disability. Moreover, claims caused by diagnosis errors made up 28% of all payouts, according to the study.
Lead researcher David Newman-Toker, a neurology professor at Johns Hopkins University, said the research confirms previous studies that showed the scope of the problem.
“Diagnostic errors are the most common, most catastrophic and most costly of medical errors,” Newman-Toker said during a webcast announcing the study.
The study, funded by the Society to Improve Diagnosis in Medicine, reviewed 55,377 closed medical malpractice claims filed from 2006 to 2015 and identified 11,592 that alleged diagnostic errors. Of those diagnosis-related claims, nearly three quarters (74.1%) were attributable to three types of conditions: cancer, vascular events such as strokes or heart attacks, and infections.
But those conditions were missed in some institutions more than others. The study found that in outpatient clinics, cancer was the most frequently missed diagnosis. In emergency departments and in hospital inpatient settings, vascular problems were the most common condition cited in malpractice claims.
Newman-Toker said the study breaks new ground in identifying specific areas where medical facilities can focus their efforts in reducing errors.
“Although diagnostic errors happen everywhere, across all of medicine, in every discipline with every disease, we might be able to take a big chunk out of this problem and save a lot of lives and prevent a lot of disability if we focused some energy on tackling these problems,” he said.
Newman-Toker said federal spending on research to prevent misdiagnosis doesn’t match the severity of the problem. He said the society estimates federal agencies spend less than $10 million on research to prevent misdiagnosis, “several orders of magnitude” less than what is needed.
A separate research report released in late June by medical malpractice insurer Coverys focused specifically on malpractice claims at hospital emergency departments. That white paper — a part of its Dose of Insight series — found that diagnosis-related claims made up 47% of malpractice claim payouts by emergency departments and 33% of the total of claims number filed. The diagnosis was the most common root cause of emergency department claims, the paper says.
“Emergency room settings are high-pressure, fast-paced environments,” said Solveig Dittmann, a senior risk specialist for Coverys. “It’s easy to let communications drop a little bit when you are called into another situation in a fast manner.”
More than 50% of inpatient hospital admissions begin in the emergency department, the Coverys white paper says. The patient’s experience there “is analogous to the first domino a chain of falling dominos.”
To prevent errors, Coverys recommends that emergency departments focus on:
- The patient history and physical examination, which was an issue in 33% of claims.
- The diagnostic decision making process, a factor in 52% of claims.
- Ensuring that patient evaluation is ongoing throughout the episode of care.
Dittmann said the experience of television actor John Ritter in 2003 shows how badly things can go wrong when a patient is misdiagnosed. She said Ritter’s physicians did not take a family history and missed that he was suffering from a ruptured aortic aneurysm. Ritter, only 54 at the time, died as a result. Providence St. Joseph Medical Center in Burbank, California paid a $9.4 million settlement to Ritter’s family, according to news reports.
To prevent errors, emergency departments should enact and enforce strict protocols for physicians, Dittmann said. They should develop a policy to require that specific elements of the patient’s and family’s medical history are documented. A template can be used to serve as a checklist.
Patients who are left waiting in the emergency room are also a frequent source of claims, said Maryann Small, director of data governance for Coverys and one of the authors of the report. While every emergency department performs triage to ensure that the most seriously sick or injured patients are treated first, sometimes medical providers forget to check in with the patients to ensure their condition has not changed, she said.
The “communication hand-off” is another key area of concern. Emergency room doctors are often called away after a patient is stabilized. Dittmann said in those instances, they must remember to brief the incoming caregiver on the current situation, the background, an assessment of the situation and a recommendation for care. Military organizations use an acronym to describe the process: SPAR, for situation, problem, action, report.
“If people remember those four things, it’s far less likely that you are going to miss something,” Dittman said.
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