Physical Medicine and Rehabilitation Malpractice Claims: Lessons Learned

Michelle Swift, JD, RN, Senior Patient Safety Risk Manager, The Doctors Company

Physiatrists, or physical medicine and rehabilitation physicians, specialize in managing conditions caused by disease or injury that affect an individual’s physical function and performance. They focus on creating patient-centered treatment plans that optimize functional well-being using medications, procedures, and physical modalities. The emphasis is on a comprehensive approach that addresses the individual’s needs, aiming to improve each patient’s overall quality of life.

The Doctors Company analyzed 119 claims against physiatrists that closed between 2010 and 2020. The study revealed the most common patient allegations: improper performance of treatment or procedure (29 percent), improper management of treatment (18 percent), those related to diagnosis (failure, delay, or wrong) (14 percent), and improper medication management (12 percent). Consider the following case examples and discussions regarding these common patient allegations.

Case Example: Improper Performance of Procedure, Failure to Diagnose a Complication, and Lack of Informed Consent

A patient referred to a physiatrist for a trigger point injection signed a generic consent form before receiving the injection. Afterward, while still in the office, the patient complained of difficulty breathing and chest discomfort. The physician, believing the symptoms were secondary to muscle spasms, treated the patient with a Lidoderm patch and recommended calling 911 for emergency assistance.

Despite the physician’s recommendation to call for emergency services, the patient refused and drove to the nearest hospital emergency department. Upon admission, a chest x-ray revealed a right-sided pneumothorax, requiring the insertion of a chest tube. Although the pneumothorax resolved eventually, the patient filed a lawsuit claiming improper performance of the trigger point injection, lack of informed consent, and failure to diagnose the pneumothorax—which resulted in a delay in receiving appropriate care.

Case Discussion

Improper Performance of Procedure and Failure to Diagnose a Complication. During the legal proceedings, expert testimony established that a pneumothorax is a recognized risk of a trigger point injection. The expert criticized the physician, however, for not promptly identifying and addressing the complication when it occurred.

Informed Consent. The plaintiff further argued that the consent form should have mentioned the risk of a pneumothorax and the discussion between the physician and patient should have been documented. These points were raised to highlight the failures in communication surrounding the procedure and its associated risks.

Although the informed consent process cannot eliminate malpractice claims, it provides the patient with realistic expectations regarding a procedure, treatment, test, medication, or overall treatment plan. An exchange of information between the patient and practitioner allows the patient to make a reasonable decision while preventing surprise, disappointment, and anger. When the discussion occurs, complete a procedure-specific form detailing the risks involved. The form should be signed by the patient and the practitioner and placed in the patient record. For more information, see our article “Informed Consent: Substance and Signature.”

Additional Patient Factors. Patient-related factors can have a significant impact on the timeliness and effectiveness of care, potentially leading to patient harm. Common patient factors include nonadherence to or refusal of recommended treatment plans and failure to obtain scheduled tests, labs, or consultations.

In this case example, the patient did not follow the physician’s advice to call for emergency services. When faced with a patient unwilling to accept or adhere to recommendations, it is essential to thoroughly document discussions and education regarding the risks of refusal. Using a refusal-to-consent form can also be helpful in such situations. For detailed guidance on managing informed refusal, see our article “Informed Refusal” and access the form on our Informed Consent Sample Forms page.

Case Example: Improper Management of Treatment

An older patient who was scheduled for a lumbar epidural steroid injection informed the physiatrist about the blood thinner medication. The physician, however, neglected to review the patient’s health history or medications before the procedure. After being discharged, the patient experienced leg weakness and urine incontinence, prompting a 911 call. An MRI revealed a lumbar epidural hematoma requiring emergency decompression. The patient filed a lawsuit due to residual paralysis.

Case Discussion

Improper Management of Treatment. During the deposition, the physiatrist admitted that the failure to gather crucial information about the patient’s health and medications contributed to the development of the hematoma and resulting complications.

Patient Assessment. To prevent patient harm and claims, review the information available in the patient record. Before any procedure, thoroughly review the patient’s history and physical, medications, laboratory tests, diagnostic studies, and consultations. This comprehensive assessment helps detect relevant factors and ensures safer and more effective care.

Procedural Time Out. Use a checklist tool to initiate a time out immediately prior to the procedure. Ensure that everyone on the team participates in the time out, and crosscheck critical information before a procedure or a prescribed treatment plan—including checking for allergies or contraindicated medications, such as anticoagulants.

Case Example: Improper Medication Management

A patient with a history of chronic pain, anxiety, and depression was found deceased at home due to a suspected medication overdose. The coroner’s report identified the combined effects of multiple pain medications, sedatives, and antianxiety medications as the cause of death.

Case Discussion

Improper Medication Management. According to the case expert, the treating physiatrists neglected to collaborate on medication prescribing—including failing to check the patient’s profile on the prescription drug monitoring program—and they did not adequately address the patient’s mental health.

Communication and Collaboration. Both components are essential elements of the patient care plan. Effective acute pain control and long-term chronic pain management require a collaborative approach among all treating practitioners. Considering the patient’s mental health history and seeking a specialty consultation would also have been appropriate in this case. Following this tragic event, changes were implemented to enhance practitioner collaboration, patient assessment, and documentation of patient care.

Additional Assistance

Analyzing closed physical medicine and rehabilitation claims offers valuable insights into the reasons behind injury allegations. By understanding the allegations and causes of patient harm, practitioners can implement measures to improve the quality of care.

For further assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.

Resource

Centers for Disease Control and Prevention, Summary of the 2022 Clinical Practice Guideline for Prescribing Opioids for Pain