Oncology Closed Claims Study

The Doctors Company conducted a review of medical and surgical oncology claims that closed between 2012 and 2018. This study was based on claims and lawsuits filed against the more than 500 oncologists insured by The Doctors Company. There were 101 medical oncology claims and two surgical oncology claims. Due to the small number of surgical oncology claims, they were excluded from the study.

Patient Injuries

Oncology patients suffered a variety of injuries. The seven most common injuries that prompted claims or suits included:

Patients may have suffered more than one harm, so the total is greater than 100 percent.

Indemnity and Expense

Only a small percentage of oncology patients’ claims (26 percent) resulted in a payment to the patient or their family.

Case Types Driving Oncology Claims and Lawsuits

There were three primary case types driving medical oncology claims. They were diagnosis related (29 percent), management of treatment (24 percent), and medication management (15 percent). The top three case types made up 68 percent of medical oncology claims.

Case types not listed above had 2 percent or fewer claims. The list included delay in treatment or procedure, improper performance of treatment or procedure, premature end of treatment, failure to warn of risks, and failure to ensure safety (falls).

Driver 1: Diagnosis Related

In diagnosis-related claims, the most common diagnoses involved secondary malignancy of the bone (14 percent), malignant neoplasm of the breast (7 percent), and secondary malignant neoplasm of the liver (7 percent). There were 21 other diagnoses with only one claim each.

The factors that contributed to patient injury in diagnosis-related claims included patient behavior factors (52 percent), inadequate patient assessments (38 percent), communication among providers (21 percent), and communication between the patient (or family members) and providers (17 percent).

Patient behavior factors were important in diagnosis-related claims. More than half of the claims and suits filed against oncologists in such cases included patients’ decisions not to attend all appointments or follow medication or treatment plans. Thus, oncologists were unable to discuss results, conduct additional studies to continue the diagnostic process, or to perform evaluations that may have uncovered symptoms of recurring cancer. Some patients also went to other, non-oncology providers when they were unhappy with their care.

Clinical assessments in oncology diagnosis-related claims were different from primary care claims. In primary care, such claims commonly demonstrated inadequate histories and physicals and/or failure to establish a differential diagnosis. Oncology diagnosis-related claims involved failure to reconcile relevant signs, symptoms, and test results, or a narrow diagnostic focus where it was presumed that the patient’s chronic condition was the cause of current symptoms.

In diagnosis-related claims, communication among providers was sometimes found to be deficient. Information regarding patients’ conditions was not always conveyed when critical information was found. In one case, results of a CT scan were communicated to the physician’s assistant but not to the attending physician or patient. Neither was aware of metastasis until 10 months later. A second case involved a patient who was incorrectly diagnosed with metastatic lesions of the lung. Other physicians doubted the diagnosis but did not communicate their concerns until the patient had received chemotherapy and a node biopsy demonstrated the lesion was benign.

Lack of communication between patients (or their families) and their physicians impacted the outcome in diagnosis-related claims. In a case where the patient had a low platelet count from chemotherapy, the patient fell at home and did not communicate this to her treating physician until after being diagnosed with an intracranial bleed. Language barrier was also a factor.

Driver 2: Improper Management of Treatment

The second-most common driver of claims was improper management of treatment (24 percent). Physician reviewers found inappropriate selection of treatment, including failure to order medications and ordering medications that were contraindicated by other medications or were not the most appropriate for the patient’s condition.

In one case, the patient’s white blood count was very low, but the decision was made to give the next chemotherapy dose. The patient’s white blood count dropped even lower. The patient began to experience intense weakness with fever and chills. She was admitted to the hospital but before medications or a blood transfusion could be started, the patient expired.

Some experts opined that the chemotherapy dose should not have been given. Others said that the patient would have experienced a poor outcome regardless of the interventions.

In another case, two numbers for the chemotherapy order were transposed, increasing the dose five-fold. The patient received the excessive dose for five days before the error was discovered, resulting in hearing loss, neuropathy, and kidney damage.

This study found that patients’ behaviors not only affected clinicians’ ability to diagnose reoccurring malignancies, they affected physicians’ ability to manage treatment. In more than one in five cases (21 percent), patient behaviors had an impact on the outcome of care. In some cases, patients looked to other providers when they were dissatisfied with care, thus eliminating the treating oncologists' ability to address patients’ concerns. Other troubling patient behaviors included failure to adhere to treatment or medication plans.

A third factor that affected oncologists’ ability to manage patients’ treatment was inadequate communication between providers and patients or their families. In some cases, patients failed to report important clinical information. In other cases, physicians did not provide adequate information about the risks of medications or inform patients about other treatment options. There were occasions of tension between physicians and patients when the physicians’ responses were not viewed as sympathetic by their patients, thus widening the communication gap. In a few cases, language barriers made communication difficult.

In one case, a patient on chemotherapy began having low-grade fevers. Her physician ordered a CBC, but the patient did not have the test performed. There was no follow-up discussion about the CBC or its importance.

At subsequent office visits for chemotherapy injections, the patient’s vital signs were not checked (or not documented). The patient’s family recorded her body temperatures during treatment, but it appears that as she became febrile, the information was not reported to her physician.

The patient presented to the emergency department in septic shock and subsequently died. Although this claim against the physician was unsuccessful, it demonstrates how failure to share information between patients, families, and providers can harm patients.

In other communication cases, patients refused to continue with treatment. Documentation was limited or did not exist regarding physicians’ conversations with patients about the consequences of refusing treatment or about other treatment options.

Driver 3: Improper Medication Management

The third driver of medical oncology claims was inadequate medication management. The factors that contributed to patient injury included inappropriate selection of therapy (47 percent), patient assessment issues (33 percent), communication among providers (33 percent), and communication between patient/family and providers (33 percent).

Inappropriate selection of therapy included ordering medications that were inappropriate for the patient’s condition or were contraindicated by other medications.

Patient assessment issues included failure to appreciate and reconcile relevant signs, symptoms, and test results. Communication among providers was most often related to changes in patients’ conditions. Communication between patient/family and provider was usually about the risks of medications.

Most of the drugs associated with oncology claims were chemotherapy/immunosuppressants. A patient with lung and metastatic brain cancer was simultaneously treated with chemotherapy and radiation. The patient received conservative doses of radiation. However, the patient expired suddenly from a suspected brain hemorrhage.

Some experts were critical of the aggressive treatment, noting a decreased quality of life and diminished life expectancy. Some noted that the oncologist failed to warn of the dangers of receiving simultaneous chemotherapy and radiation treatment. A few experts observed that while the treatment was aggressive, it was not outside the standard of care. The case was not pursued.

In several cases, patients received excessive doses of chemotherapy. Pump malfunctions or incorrect settings resulted in patients receiving very large doses. In other cases, patients reacted to the drugs but were maintained at a high level or kept at a low dose for too long. Some patients experienced severe neutropenia, thrombocytopenia or pancytopenia, sepsis, and/or lung and cardiac damage. In one case, experts opined that the patient had been expected to recover but suffered life-altering injuries from excessive medication doses.

In a few cases, anticoagulants were not managed properly, resulting in hemorrhages and brain damage or loss of an appendage. In one case, the physician was aware of the heparin-induced thrombocytopenia but failed to change to an appropriate anticoagulant immediately. This resulted in below-the-knee amputations.

Risk Mitigation Strategies

1. In 29 percent of oncology claims, patients alleged that there was a failure or delay in diagnosing the patient’s illness. Some were initial diseases and others were secondary malignant neoplasms of the bone or marrow (14 percent of diagnosis-related claims). The most frequent factor contributing to patient harm was inadequate assessments. Physicians are responsible for thorough assessments and documentation of their findings. This is especially true when patients’ conditions change.
2. The second-most common case type (24 percent) was related to treatment management. In some cases, patients did not have tests performed. In other cases, tests were completed, but information was not reviewed by the ordering physicians. It is essential to track and review all test results for tests that are ordered. Failure to log and track orders for diagnostic tests increases the chance that important information will not be received.
3. Patients are important members of the healthcare team. They need to receive information required for making informed decisions about care and treatment. When patients refuse to proceed with treatment recommendations from their physicians, physicians should document the information provided, the patient’s decision-making process, and their final decision.
4. Patients are an important source of information, but they may not know what information should be shared with their physicians. Physicians should help patients understand the information that physicians need, such as changes in their condition, reactions to medications, falls and other trauma, and supplemental treatments that patients adopt that are not part of their oncologist’s recommendations.
5. In 9 percent of oncology claims and suits, patients chose to seek care from a different physician. This eliminated the opportunity for original treating oncologists to address patients’ concerns. Open communication with patients is essential for eliciting important information and encouraging candid revelations from patients. It also appears to improve adherence to treatment plans.
6. The healthcare team is essential for catching inadvertent errors in medication orders and other medication-related treatment. Create an environment where anyone can raise a concern, thus increasing the chance that errors will be identified and communicated before patients are harmed.
7. Practices should fulfill their obligations to provide language assistance for patients whose treatment may be impeded by language barriers. Translators should accompany patients who have language barriers.
8. Physicians should supervise nurse practitioners and/or physician assistants as appropriate in their respective states.

Oncology patients are often very ill and fragile. Medical errors can be devastating. Healthcare environments that encourage open communication increase the chances that patients or staff will speak up when they have concerns. Well-designed office systems can identify missing consult reports and test results.

Use every tool available to maintain current information on patients. This information provides the opportunity to respond quickly to patients’ changing conditions and to address patients’ needs. The quality and length of patients’ lives often depend on it.