An Analysis of Internal Medicine Malpractice Claims
A total of 369 closed internal medicine claims from 2000 through 2007 were reviewed to identify events that place internists at risk for a malpractice claim.
These included subspecialty claims in cardiology, gastroenterology, hematology, infectious disease, and immunology. All claims are from The Doctors Company’s Columbus office (formerly OHIC Insurance Company).
The Executive Information System (a case-based data-mining tool) was used to analyze the claims data on these internal medicine claims. The analysis was performed to identify events that lead to a malpractice claim, regardless of whether there was negligence. Therefore, claims with and without indemnity payments are included. A subset of claims involving hospitals and nursing homes is also included, but only when there was also a claim against an internist.
Overview of Claims
In these 369 claims, 58 percent of the allegations were related to diagnosis, 23 percent were related to medical treatment, 9.5 percent were related to improper medication management, 2.2 percent involved ordering errors, 1.6 percent involved patient monitoring, and 5.7 percent were miscellaneous.
The 58 percent of claims that allege diagnosis-related negligence are subdivided into those involving failure to make the correct diagnosis and those resulting from diagnostic delay (Table 1).
The 23 percent of claims that allege negligence related to medical treatment are subdivided into seven categories (Table 2).
A total of 9.5 percent of claims alleged medication-related negligence, and 58 percent of these claims involved medication management.
A total of 2.2 percent of claims alleged negligence resulting from ordering errors. Of these claims, 75 percent resulted from failure to order, and 25 percent involved a wrong dose.
Repetitive Clinical Events
When the clinical summaries of these 369 claims were reviewed, the events that led to the claim were unique and nonrepetitive in 239 claims. Further analysis of these claims was not pursued since there were no patterns from which generalizations could be drawn. However, the remaining 130 claims contained repetitive clinical events. This subset was further analyzed to identify recurrent patterns of error or clinical circumstance that might suggest future subject areas for continuing medical education (CME) or maintenance of certification (MOC) programs to focus on.
Of these 130 repetitive claims, 67 percent of the allegations were related to diagnosis, 21 percent were related to improper medication management, 9 percent were related to improper management and/or treatment, and 3 percent involved patient monitoring.
- Diagnosis-Related Claims: The 67 percent of repetitive claims that alleged diagnosis-related negligence resulted from both diagnostic delays and failure to diagnose. They are subdivided into five clinical diagnostic categories: (a) cardiovascular events, (b) neoplasms, (c) infections, (d) gastrointestinal events, and (e) claims involving thrombotic thrombocytopenic purpura (TTP).
- Cardiovascular events: 48 percent of the diagnosis-related claims involved cardiovascular events (55 percent when atrial fibrillation is included; it is also listed as a medication-management related event). Of these cardiovascular events, 23 percent involve myocardial infarction (MI), 21 percent involve pulmonary embolism, 19 percent involve aortic aneurysm (over half were dissecting aneurysms), 12.5 percent involve atrial fibrillation, and 12.5 percent involve failure to diagnose arteriosclerotic heart disease (ASHD). These are listed in Table 3.
- Neoplasms: 31 percent of the diagnosis-related claims involved neoplasms. Of these claims, 79 percent resulted from a delay in diagnosis and 21 percent from failure to diagnose. The cancers (Ca) involved are listed in Table 4.
- Infections: 9 percent of the diagnosis-related claims involved infections. Half resulted from failure to timely diagnose epidural abscess (#4) resulting in paraplegia and/or incontinence, and half resulted from failure to diagnose osteomyelitis (#4: two were vertebral, one foot, and one sternoclavicular joint). Three of the epidural abscesses were associated with a urinary tract infection and one with a methicillin-resistant Staphylococcus aureus (MRSA) septicemia.
- Gastrointestinal events: 8 percent of diagnosis-related claims involved gastrointestinal events. These were almost evenly divided between failure to timely diagnose appendicitis resulting in rupture and peritonitis (#3) and acute pancreatitis (#4).
- Thrombotic thrombocytopenic purpura: 3.5 percent of repetitive diagnosis-related claims involved TTP. One was in a patient with systemic lupus erythematosus (and misdiagnosed as lupus cerebritis); one followed administration of Lovenox + Ticlid, resulting in seizures and death; and one followed a quinine dose, resulting in a hemolytic uremic syndrome with renal failure necessitating renal transplant.
- Improper Medication Management Claims: Improper medication management was alleged in 21 percent of repetitive claims (Table 5). Note that 59 percent (#16) of these medication management events involved anticoagulants and that 81 percent (#13) of anticoagulant claims involved Coumadin. Furthermore, 46 percent of the Coumadin claims resulted from failure to monitor using the international normalized ratio (INR).
- Improper Management and/or Treatment Claims (9 percent) Included:
- TIA improper management (#3)—resulting in cerebrovascular accident (CVA)
- Hypertensive patients with TIA (#3)—resulting in CVA
- Hypertension, improper management (#3)—resulting in cerebral hemorrhage
- Hyperkalemia, improper management (#2)—resulting in fatal cardiac arrhythmia
- Acute MI, improper management (#1) of fatal cardiogenic shock
- Patient Monitoring Claims (3 percent) Included:
- Jugular vein occlusion (#1)—in a patient receiving heparin through a subclavian vein catheter
- Failure to monitor blood pressure post cardiac catheterization (#1)—a defective Angio-Seal at the inguinal catheter site caused fatal retroperitoneal bleeding
- Axillary vein thrombosis (#1), while placing a jugular vein catheter resulted in arm amputation
- Femoral artery laceration (#1), while placing a Swan-Ganz catheter caused fatal hemorrhage
Repetitive Clinical Events for CME and MOC Program Focus
Repetitive patterns of error that lead to adverse outcomes and malpractice claims suggest clinical risk management and patient safety topics appropriate for CME and MOC programs. The following subject areas—repetitive diagnosis-related, medication-related, and management/treatment-related events—are candidate topics. While these claims are from The Doctors Company’s Columbus office, in the author’s experience they are representative of repetitive events seen in internal medicine claims throughout the country.
Diagnosis-Related Events:
- Myocardial infarction
- Pulmonary embolism
- Atrial fibrillation
- Dissecting aortic aneurysm
- Lung and rectal cancer
- Epidural abscess
- TTP
Medication-Related Events:
- Anticoagulant management—Coumadin and heparin
- Monitoring Coumadin with the INR
- Monitoring gentamicin with drug levels
- Antibiotics for pneumonia
Management and Treatment Events:
- Hypertension management
- TIA management
Risk Management and Patient Safety Issues
These 369 claims were also analyzed for physician risk management and institutional risk management patient safety issues. A total of 659 risk management/patient safety events were identified. Those events that can be assigned to specific categories are classified as follows:
29 percent involved patient assessment:
- 21 percent failure/delay ordering diagnostic test
- 18 percent failure to establish differential diagnosis
- 13 percent lack/inadequate clinical information assessment-note
- 11 percent failure to rule out abnormal finding
- 7 percent failure to respond to patient’s concerns
- 6 percent narrow diagnostic focus
- 5 percent rely on negative findings with continuing symptoms
- 4 percent misinterpretation of diagnostic studies
- 3 percent premature discharge
- 3 percent relying on previous diagnosis
- 2.5 percent atypical presentation
- 2 percent lack/inadequate history and physical
11 percent involved selection and management of therapy (57 percent are medication related):
- 37 percent medical therapy
- 11 percent medication therapy—inappropriate for medical condition
- 10 percent medication therapy—failure to order medication
- 6 percent surgical/invasive procedures
- 5 percent medication therapy—not most appropriate
- 2 percent medication therapy—contraindicated other medication
- 29 percent medication therapy—other
11 percent involved communication between patient/family and providers (20 percent involve informed consent):
- 32 percent poor patient rapport
- 14 percent inadequate consent for treatment option
- 10 percent patient/family education—risks of medications
- 6 percent patient/family education—patient care in hospital
- 6 percent inadequate consent for surgical procedure
- 2 percent patient/family education—follow-up instruction
- 30 percent communication—other
10 percent involved patient factors:
- 19 percent patient noncompliance with follow-up call/appointment
- 18 percent patient noncompliance with medication
- 18 percent patient noncompliance with treatment regimen
- 37 percent other
9 percent involved communication among providers:
- 83 percent communication involving patient’s condition
- 12 percent failure to read the medical record
- 1 percent poor professional relationship/rapport
- 4 percent communication—other
8 percent involved insufficient/lack of documentation:
- 21 percent clinical history
- 15 percent follow-up efforts
- 14 percent clinical rationale
- 11 percent review of care
- 11 percent clinical findings
- 4 percent date/time
- 3 percent patient phone advice
- 1.4 percent adverse event
- 1.4 percent informed consent
- 1.4 percent refusal of treatment
- 17 percent other
7 percent involved patient monitoring:
- 74 percent physiological monitoring
- 23 percent medication regimen
- 2 percent behavioral status
6 percent involved failure/delay to obtain consult/referral:
- 3 percent involved policy/protocol
2 percent involved lack of or failure in patient follow-up system:
- 53 percent involved new findings
- 33 percent involved routine screening
- 13 percent involved ongoing monitoring
1.5 percent involved medical record related issues
1.5 percent involved reporting findings/revised findings:
- 55 percent results filed before clinical review
- 27 percent results not received by clinician
- 18 percent patient did not receive result
Conclusion
We are publishing this analysis of closed internal medicine claims because we believe that malpractice claims are a valuable source of information on preventable medical error and that disclosing this data will contribute to the advancement of patient safety. We will continue to examine important risk management and patient safety issues and to publish this information to advance the practice of safe medicine. We invite you to explore our online library of articles at www.thedoctors.com/patientsafety.
J7278 3/09
By David B. Troxel, MD, Medical Director, Board of Governors.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.