Study Examines Hospitalist Malpractice Claims

By Floyd Arthur

On the front lines of acute care medicine, hospitalists work under circumstances that are

far from ideal. Not only are they directly responsible for multiple patients with complex

medical needs, they are often forced to accept patient loads that they identify as unsafe.

Hospitalist Malpractice Claims

According to a 2013 survey of 890 hospitalists published in JAMA Internal Medicine, 40

percent of hospitalists report carrying an unsafe patient load at least once a month. Over

35 percent report unsafe patient loads more than once a week. According to the doctors

themselves, this leads to communication failures and diagnostic and treatment errors

that often result in significant harm.

Allegations In Hospitalist Malpractice Claims

Hospitalists are not sued more often than physicians in any other speciality. However,

malpractice claims against hospitalists often involve serious injuries or death. In an

attempt to identify practice patterns that result in the most serious patient injuries, The

Doctors Company analyzed medical malpractice claims against its 2,100 member

hospitalists that closed between 2007 and 2014. All claims, regardless of outcome, were

included in the analysis. A total of 464 claims were reviewed.

A review panel of physician experts examined the claims and categorized them based on

the nature of the allegations. Seventy-eight percent fell into three categories: diagnostic

errors (36 percent); treatment errors (31 percent); and medication-related errors (11 percent.)

The remaining categories were improper performance, such as improperly placed

central venous catheters, (5 percent); delay in treatment (3 percent); and failure to

monitor patient status (3 percent).

Factors Contributing to Hospitalist Malpractice Claims

Multiple factors were identified as contributing to the majority of hospitalist malpractice

claims.. Seventy-four percent of these were in three main categories: patient

assessment, provider communication and therapeutic interventions.

Patient Assessment

Thirty-five percent of the diagnostic and treatment errors identified in the study were

due to inadequate patient assessment, including:

* Failure to establish a differential diagnosis

* Failure or delay in ordering diagnostic tests

* Failure to consider available information (e.g. lab values, observations, signs and symptoms)

Example 1: A 20-year old female was admitted through the ER with a history of fever,

chills and pain radiating from her back to her right side. A chest X-ray showed a right

lower lobe infiltrate; her oxygen saturation was 86 to 89 percent, and blood work

revealed elevated D-dimers.

The hospitalist put the patient on IV antibiotics for a diagnosis of pneumonia and

ordered pulmonary and infectious disease consults. Later, the patient became

disoriented and complained of increasing shortness of breath. She died soon afterwards.

The cause of death was a pulmonary embolus.

The hospitalist’s failure to consider the elevated D-dimers, include PE in the differential

diagnosis and order further diagnostic tests were identified as factors that contributed to her death.

Provider Communication

Breakdowns in communication between nursing staff, consulting physicians and the

hospitalist were identified as a factor in 23 percent of medical malpractice claims. These

included nurses failing to notify the responsible hospitalist of important clinical findings

and physicians failing to note findings mentioned in the patient’s chart.

Example 2: A 49 year-old male was admitted through the ER with chest and back pain,

headache, and numbness and tingling in his lower extremities. On admission the blood

pressure in his right arm was 154/53; it was 117/56 on the left. The nurse failed to

document this discrepancy in the medical record or bring it to the attention of the

hospitalist. The patient was discharged and subsequently collapsed and died at home.

The cause of death was mediastinal hemorrhage due to an aortic dissection.

The lack of communication between the nursing staff and the hospitalist were identified

as critical factors in the patient’s death.

Therapeutic Interventions

In 16 percent of the malpractice claims reviewed, the hospitalist’s choice of therapy was

identified as a factor in a patient’s injury or death. This category included improper

selection of appropriate therapy; failure to order appropriate medications; ordering

inappropriate medications; and ordering no medication at all. Breakdowns in

communication between providers, patients and families and nursing staff were also a

factor in several of these claims.

Example 3: A 75 year-old female was admitted to the hospital with a diagnosis of

pneumonia and uncontrolled Type 2 diabetes. The hospitalist treated her pneumonia

appropriately and placed her on a sliding-scale of regular insulin and Lantus. Two days

later, as the patient’s pneumonia was improving, a second hospitalist took over her care.

He changed her insulin to twice daily Humalog, after which she experienced several episodes of

hypoglycemia. The patient subsequently arrested and died. Her last blood glucose was 15 mg/dL.

The panel identified the failure of the nursing staff to adequately communicate the patient’s

repeated episodes of hypoglycemia to the hospitalist as well as the hospitalist’s decision to

change her insulin without consulting an endocrinologist as factors in the patient’s death.

Advice for Hospitalists: Strategies for Managing Risk

In its assessment of the above findings, the physician panel identified “weaknesses in

the systems and processes used by members of the healthcare team” as a major

contributor to preventable errors that result in significant patient harm. These

undoubtedly include staffing shortages, unpredictable patient census, and unwieldy

electronic health records that make important clinical information difficult to find.

Nonetheless, the study reveals some areas where physicians can improve patient

management and mitigate the risks inherent in the hospitalist’s role. Some

recommendations from the panel include:

* Order diagnostic tests promptly and involve other specialties early when the differential

includes diagnoses that have the potential to result in serious harm.

* Build rapport with patients early in their hospital stay.

* Understand that the hospitalist’s role is to integrate and coordinate patient care.

* Remain accessible to nursing staff and consulting services throughout the patient’s hospital stay.

* Review all documentation carefully and question information that is unclear.

* Be cognizant of emerging pathology, especially when the differential includes a number of similar diagnoses.

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