We tend to think about diagnostic errors leading to malpractice claims as primarily problems on the outpatient side, mainly because most medical care is rendered on the outpatient side (see, for example, our March 2013 What's New in the Patient Safety World column “Diagnostic Error in Primary Care”). However, diagnostic errors occur in all venues of the healthcare system.
A previous study of types of malpractice claims (Tehrani 2013), using data from the National Practitioner Data Bank (1986–2010), found that diagnostic errors were the leading type (28.6%), were more likely to be associated with death and disability, and accounted for the highest proportion of total payments (35.2%). More diagnostic error claims were outpatient than inpatient (68.8% vs 31.2%) but inpatient diagnostic errors were more likely to be lethal (48.4% vs 36.9%).
Now, a more recent study looked at malpractice claims resulting from inpatient diagnostic errors (Gupta 2017). Gupta and colleagues looked at over 60,000 paid malpractice claims in the US National Practitioner Database and found that 22% were diagnosis-related. Diagnosis-related paid claims were associated with 1.83 times more risk of disability and 2.33 times more risk of death compared with other paid claim types. Median diagnosis-related payments also increased at a rate disproportionate to other claim types.
Diagnosis-related paid claims were more likely to be associated with male patients, patient aged >50 years, provider aged <50 years, and providers in the northeast region.
A study from the Doctors Company, a large physician malpractice insurer, reported percentage of diagnosis-related malpractice claims by specialty (Troxel 2014). It found that 34 percent of nonsurgical specialty claims were diagnosis related (the number one allegation in these claims). For surgical specialties, 14 percent were diagnosis related (the third most common allegation in these claims). That report did not break down inpatient vs. outpatient claims. But claims for hospitalists, most of which presumably were on inpatients, 34% of claims were diagnosis-related.
Another study from the Doctors Company (Ranum 2016) reported on claims against hospitalists and found that 36% of claims were diagnosis-related. 35% of those cases resulted from an inadequate initial assessment. Often the cases with patient assessment issues included the following:
Claims arising from hospitalist care are more likely to have a higher injury severity than other physician specialties.
The authors ascribe some of the risk to the fact that hospitalists manage high-acuity patients, have limited access to patients’ past medical histories, and often receive patients with serious conditions. They note that these situations require thorough assessments, comprehensive testing, quick diagnoses, timely referrals, and rapid initiation of treatment. They stress that some conditions may have similar presentations (eg. pneumonia and pulmonary embolism) so having a good differential diagnosis is important. But they also note that some less common conditions (eg. spinal epidural abscess) are beginning to appear more frequently in claims.
Some of our prior columns on diagnostic error:
Gupta A, Snyder A, Kachalia A, et al. Malpractice claims related to diagnostic errors in the hospital. BMJ Qual Saf 2017; Published online 9 Aug 2017
Tehrani ASS, Lee HW, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank
BMJ Quality & Safety 2013; 22(8): 672-680
Troxel DB. Diagnostic Error in Medical Practice by Specialty. The Doctor’s Advocate (The Doctors Company) 2014; Third Quarter 2014
Ranum D, Troxel DB, Diamond R. Hospitalist Closed Claims Study. An Expert Analysis of Medical Malpractice Allegations. The Doctors Company 2016