Avoid a Lawsuit
Abstract & Commentary
By Joseph Varon, MD, FACP, FCCP, FCCM, Professor, University of Texas Health Science Center, Houston; Adjunct Professor of Medicine, University of Texas Medical Branch at Galveston. Dr. Varon reports no financial relationship to this field of study.
Synopsis: Malpractice claims due to diagnostic errors in the ambulatory setting are common and are the result of multiple breakdowns and individual and system factors. Clinical knowledge and proper follow up are essential to avoid these claims.
Source: Gandhi TJ, et al. Ann Intern Med. 2006;145:488-496
This retrospective study was aimed at evaluating the factors involved in litigation proceedings involving diagnostic errors in the ambulatory setting. The study was designed as a retrospective review of 307 closed malpractice claims in which patients alleged missed or delayed diagnoses. Data was extracted from random samples of closed claim files of four malpractice insurance companies based in 3 regions of the United States. Each company insured approximately 21,000 physicians. A claim was defined as a written demand for compensation for medical injury. Those claims involving missed or delayed diagnoses were those alleging an error in diagnosis or testing that caused a delay in appropriate treatment or the failure to act or follow on the results of a diagnostic test. The claims were divided into 2 primary categories: those involving care in the emergency department (ED) and those in all other locations (ie, doctor's office, pathology laboratory, radiology suites). The operational definition of "error" was based on the Institute of Medicine definition. Throughout the study period (1984-2004) there were 307 diagnosis-related ambulatory claims closed. Seven hundred and thirty patients we studied. Of them, 181 claims (59%) were considered to truly have errorin diagnosis and/or delay in initiation of therapy. Errors in 106 of these (59%), were associated with significant or major adverse outcome and 30% were associated with death. Cancer was the most common missed diagnosis (59% of cases), mainly breast cancer, followed by colorectal and skin cancer. Other missed diagnoses included infections, fractures, and myocardial infarctions. Most errors occurred in physicians' offices (85%). The mean interval between when diagnosis should have been made and when it was made (that is, in the absence of an error) was 465 days. The primary break-down points found were the failure to order an appropriate diagnostic test (55%), failure to create a proper follow up (45%), failure to obtain an adequate history or physical examination (42%), and incorrect interpretation of the test(37%). Imaging studies were the most common diagnostic tests not ordered. The explanation for the failure to order a test was mainly a lack of knowledge of the proper test to request. Other factors that contributed to errors included failure in judgment (70%), vigilance or memory (59%), knowledge (48%), and patient-related factors (46%). The median number of factor contributing to a medical error was three (range 2-4).
Commentary
Missed or delayed diagnoses in the ambulatory setting were common in this cohort. This study is interesting because it reaffirms that errors do occur for a variety of reasons and most of them are preventable. For example, over half of the diagnoses in this study were cancer-related and yet, lack of follow up was one contributing factor for a claim. This is particularly bothersome as primary clinicians are inundated with a variety of guidelines regarding the interpretation and follow up of abnormal results. Previous studies have shown that primary care clinicians do not follow up abnormal mammograms in up to one third of patients.1 In addition, a delay in reviewing diagnostic test results has been reported in the primary care setting.2
Another problem noted by this study is a process breakdown. Clinicians need to find ways to safeguard their patients with mechanisms that allow them to review diagnostic test results in a timely fashion. Follow up is essential and could avoid litigation in many instances.
References:
1. Haas JS, et al. J Gen Intern Med. 2000;15:321-328.
2. Poon EG, et al. Ann Intern Med. 2004;164: 2223-2228.
Malpractice claims due to diagnostic errors in the ambulatory setting are common and are the result of multiple breakdowns and individual and system factors.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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