Diagnostic Missteps Kindle Claims Against Hospitalists

Marcia Frellick

March 07, 2016

SAN DIEGO — The most common claim in malpractice lawsuits against hospitalists is that a diagnosis was not made, was delayed, or was incorrect, according to a closed claims study.

"This study brings to light the particular challenges faced by hospitalists who manage high-acuity patients, have limited access to patients' medical histories, and often receive patients with serious conditions," David Troxel, MD, medical director of The Doctors Company, a physician-owned medical malpractice insurer, said in a news release.

The data were released here at the Society of Hospital Medicine 2016 Annual Meeting.

Dr Troxel and his colleagues analyzed 464 claims against the 2100 hospitalists the company insures that closed (no matter how they were settled) from 2007 to 2014.

They found that 36% of the claims were related to diagnoses, including missed, late, or incorrect diagnoses. And, of those claims, 35% resulted from an inadequate initial assessment, "consequently decreasing the chance that the hospitalist would arrive at the correct diagnosis," the researchers report.

Intestinal disorders — such as obstruction, perforation, and vascular insufficiency — were the most common of the conditions involved in incorrect or delayed diagnoses.

Table: Conditions Most Commonly Involved in Diagnostic Delays, Errors

Condition Percent of Claims
Intestinal disorders (obstruction, perforation, and vascular insufficiency) 16
Cerebral artery occlusion and acute cerebral vascular accident 7
Acute myocardial infarction and cardiac arrest 6
Sepsis and toxic shock syndrome 5
Pulmonary embolism 5
Spinal epidural abscess 4
Lung cancer 4
Viral and bacterial pneumonia 3
Subacute and acute endocarditis 3
Aortic dissection or aneurysm 3

 

Spinal epidural abscess caught the eye of John Nelson, MD, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Washington, and national expert on hospital medicine practice management.

The condition is rare — a hospital might see one case a year — but it is appearing more in malpractice claims, Dr Troxel's team reports.

"The lesson is make sure you understand the disease well," Dr Nelson told Medscape Medical News. "It is a very tricky thing. Studies of that illness, in particular, have shown that doctors typically don't figure it out right away."

Symptoms of spinal epidural abscess include neck or back pain, loss of neurologic control or sensation, and fever, according to the researchers. If it is suspected, an MRI should be ordered to confirm the diagnosis and a surgeon should be consulted early on.

Poor communication was the next-biggest factor contributing to harm, at 23%. In some cases, nurses identified patients who were at risk for deep vein thrombosis or pulmonary embolism whose neurologic status changed, but did not notify a physician.

In other cases, physicians missed information documented in the medical record and were therefore unaware of changes in the patient's condition or care.

A Very Sick Population

The researchers report that claims arising from hospitalist care involve more severe injuries than those from other physician specialties. The severity of injury was high in 72% of the patients being cared for by hospitalists, medium in 22%, and low in 6%. In contrast, the severity was high in 34% of patients being cared for by all physicians, medium in 52%, and low in 13%.

It is important to consider these comparisons, said Joseph Ming Wah Li, MD, associate professor of medicine at Harvard Medical School and chief of hospital medicine at the Beth Israel Deaconess Medical Center in Boston, who was not involved in the study.

"When you say 'all physicians,' you are including, perhaps, dermatologists and a number of outpatient providers. Maybe a better comparison would be hospital-based specialists, like emergency department physicians or general surgeons," Dr Li told Medscape Medical News.

He said he agrees with the factors mentioned in the study that point to the risks for more serious claims. Among them is the fact that hospitalists take care of a very sick population. Many patients are elderly and often have chronic medical conditions that require multiple medications.

In addition, physicians are generally less likely to be sued if they have a pre-existing relationship with a patient, which hospitalists generally don't have, he pointed out.

Another challenge is that hospitalists don't often have timely access to a patient's medical record. "In every hospital in this country, peak admission hours are generally late afternoon or early evening," which can make timely access to information difficult, he said.

 
These are all issues that can be fixed. It doesn't mean that we can't take care of an acutely ill population.
 

The initial management of surgical patients can also raise the risk for hospitalists, Dr Li explained. It is often not easy to convince a doctor in another specialty to come in the middle of the night.

"Hospitalists are not surgeons, they're not neurosurgeons. But sometimes hospitalists are being asked to care for these patients when they present. That may lead to the issue of inaccurate diagnosis," he added.

Dr Li said he encourages hospitalists to take a positive approach to these study results.

"These are all issues that can be fixed," he said. "It doesn't mean that we can't take care of an acutely ill population. We should be able to create a system where you can get timely access to records. We should be able to fix the issue of comanaging patients. We have more of a systems problem than a hospitalist problem."

Dr Troxel and his colleagues are employees of The Doctors Company. Dr Li has reviewed medical malpractice cases for attorneys whose clients were insured by The Doctors Company, but has no direct relationship to the company, and he is a member of Medscape's advisory board. Dr Nelson is an unpaid member of The Doctors Company advisory board, but was not involved in the study.

Society of Hospital Medicine 2016 Annual Meeting.

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