Emergency Medicine Malpractice Claims Data & Risk Analysis€¦ · 2 0 1 6 Malpractice Claims Data & Risk Analysis 2 This publication contains an analysis of the aggregated data from

E M E R G E N C Y

M E D I C I N E

2 0 1 6

Malpractice Claims Data & Risk Analysis

PAT I E N T S A F E T Y &

R I S K S O L U T I O N S

22 0 1 6 Malpractice Claims Data & Risk Analysis

This publication contains an analysis of the

aggregated data from MedPro Group’s

emergency medicine claims opened between

2005 and 2014. All claims included in this

analysis identify an emergency medicine

physician as the primary responsible service.

Claims in which another specialty is identified

as the primary responsible service are not

included, unless otherwise noted.

This analysis is designed to provide MedPro

Group insured doctors, healthcare

professionals, hospitals, health systems, and

associated risk management staff with detailed

claims data to assist them in purposefully

focusing their risk management and patient

safety efforts.

Data are based on claim counts, not on dollars

paid (unless otherwise noted). The type of

claims and the details associated with them

should not be interpreted as an actuarial study

or financial statement of dollars paid; however,

the information may be referenced for issues of

relativity.

Please Note: This report is divided into two

sections — an executive summary and a more

detailed analysis of allegations and risk

factors. The executive summary begins on

page 3, and the detailed analysis begins on

page 7.

I N T R O D U C T I O N

2 0 1 6 3

E X E C U T I V E

S U M M A R Y

Malpractice Claims Data & Risk Analysis2 0 1 6 4

Diagnosis-Related Treatment-Related

Medication-Related Other

C L A I M V O L U M E B Y A L L E G AT I O N C AT E G O R Y

Medication-related allegations currently represent a relatively small segment of emergency medicine claims.

However, trends show these claims increasing, in part due to adverse events related to prescription narcotics.

Over the 10-year period analyzed,

diagnosis-related allegations accounted

for 64% of all emergency medicine

claims. Further, diagnosis-related

allegations accounted for 82% of total

dollars paid for defense and indemnity

costs. In recent years, diagnosis-related

allegations have accounted for 70% of

all claims, showing that the trend

continues to grow. 64%

7%

6%

23%


D I A G N O S I S - R E L AT E D A L L E G AT I O N S B Y D I A G N O S I S T Y P E

Myocardial infarctions (MIs), which fall

into the “cardiac (noninfective)”

category, are the single most frequent

diagnosis noted in emergency

medicine diagnosis-related claims;

however, infections as a broad

grouping represent the largest volume

of diagnosis-related claims (specific

infections noted in these claims

include pneumonia, sepsis,

endocarditis, and, most recently,

spinal abscesses).

Infection

Cardiac (Noninfective)

Cerebrovascular Accident (CVA)

Fracture

Appendicitis

Cancer

Aortic Aneurysm

Pulmonary Embolism (PE)

Nonaortic/Cerebral Vascular

Diagnosis

Traumatic Cerebral Bleed

Cauda Equina

Testicular Torsion

Other

29%

18%

9%

8%

7%

6%4%4%3%

3%

3%

3%

2%


Poor patient assessment, including

inadequate history taking, test/consult

ordering, and reevaluation of patients

prior to discharge

Failure to follow policies and procedures,

particularly those related to triage,

medication monitoring, and reevaluation

of patients admitted but not transferred

from the ED

Inadequate communication among providers

(particularly related to shift changes and

other handoffs) and poor collaboration

between physicians and nurses

Patient noncompliance due to poor

discharge instructions or lack of follow-up

Inconsistent and incomplete documentation

that does not support the final diagnosis or

include adequate details about the differential

diagnosis

Inadequate supervision of advanced

practice providers

Poor tracking systems that prevent

postdischarge test results from reaching

patients or their physicians

EHR systems that prevent providers from

accessing all relevant findings, changes,

and prior records

K E Y R I S K FA C T O R S

2 0 1 6 7

D E TA I L S


C L A I M V O L U M E B Y A L L E G AT I O N C AT E G O R Y

64%

7%

6%

23%

Diagnosis-related allegations involve failure to diagnose or delay in diagnosis. These allegations account for 82% of

total defense and indemnity dollars paid.

Treatment-related allegations are related to improper management of treatment and improper performance of

treatment/procedures. Related outcomes include infections and scarring after suturing, constriction injuries following

application of splints, injuries related to intubation technique, and improper management of behavioral health issues,

cardiac arrest, and CVAs.

Medication-related allegations include improper ordering of medications, insufficient monitoring/documentation of at-

risk patients’ responses to narcotics (e.g., patients who have sensitivity issues or a history of obstructive sleep apnea),

improper administration/management of anticoagulant regimens (resulting in overdose), and delayed administration of

tissue plasminogen activator (tPA).

Other allegations include those for which no significant claim volume exists. Examples include discrimination and

breach of confidentiality issues.

82%

10%

3% 5%

Total dollars paid

Diagnosis-Related

Medication-Related

Treatment-Related

Other


Treatment-Related

Diagnosis-related allegations remained the top allegation category over the 10 years analyzed and

are trending higher as a percent of total cases.

A L L E G AT I O N T R E N D I N G O V E R T I M E

2005-2007 2006-2008 2007-2009 2008-2010 2009-2011 2010-2012 2011-2013 2012-2014

80%

70%

60%

50%

40%

30%

20%

10%

0%

% o

f C

ase

s

Diagnosis-Related Medication-Related Other


C L A I M V O L U M E B Y C L I N I C A L S E V E R I T Y

70%

60%

50%

40%

30%

20%

10%

0%

% o

f C

ase

s b

y S

eve

rity

Le

ve

l

High Medium Low

63%

30%

7%

High-severity claims most

often are associated with:

• MIs

• PEs

• CVAs

• Aortic aneurysms

Medium- and low-severity

cases have outcomes such as:

• Manageable infections

• Need for additional surgical

procedures

• Prolonged hospital stays

• Unanticipated scarring


D I A G N O S I S - R E L AT E D A L L E G AT I O N S B Y D I A G N O S I S T Y P E

• Failure to access patients’ prior medical records

• Patient flow issues related to wait times for consults

and tests, which result in failure to order as indicated

• Inadequate patient assessment, which results in

narrow diagnostic focus. Potential causes of this risk

factor include cognitive biases, inadequate medical

and family history taking, and inadequate sharing of

information among providers

• Inadequate patient reassessment, which results in

premature discharge

• Failure to communicate test results received

postdischarge to the patient or the patient’s physician

Significant Risk Factors in Diagnosis-Related Claims

Note: MIs — which fall into the cardiac (noninfective) category — are the largest individual diagnosis (8% of

all diagnosis-related allegations).

29%

18%

9%

8%

7%

6%4%4%3%

3%

3%

3%

2%

Infection

Cardiac (Noninfective)

Cerebrovascular Accident (CVA)

Fracture

Appendicitis

Cancer

Aortic Aneurysm

Pulmonary Embolism (PE)

Nonaortic/Cerebral Vascular

Diagnosis

Traumatic Cerebral Bleed

Cauda Equina

Testicular Torsion

Other


T R E AT M E N T- R E L AT E D A L L E G AT I O N S

Treatment-related allegations, although not the

largest allegation category, can be significant in

terms of poor patient outcomes. These allegations

typically are related to faulty triage, including:

• Problems associated with assessment and

observation in the waiting room

• Failures in reassessment and monitoring of

patients admitted but not transferred from the

emergency department (ED)

• Failure to treat conditions such as CVAs in a

timely manner


T O P R I S K FA C T O R S I N A L L C L A I M S

Risk factors are broad areas of concern that may have contributed to allegations, injuries, or initiation of claims. Because the

decision-making process in a fast-paced ED setting is complex, the factors are varied.

80%

70%

60%

50%

40%

30%

20%

10%

0%

90%

100%

Clinical Judgment Communication Documentation Administrative Clinical Systems

% o

f C

ase

s W

ith

Asso

cia

ted

Ris

k F

acto

r 89%

40%

24%21% 19%

Poor communication among providers

Inadequate communication with patients, particularly in medication-related claims

Insufficient charting of clinical findings and treatment rationale

Failure to document differential diagnosis and evidence to support final diagnosis

Failure to follow established

protocols, specifically triage

(level assigned and waiting

room monitoring), medication

protocols, critical test result

notifications, boarded patient

reassessments, and advanced

practice provider consultations

Inadequate patient history and assessment

Failure to order consults or tests

Maintaining a narrow diagnostic focus

Encompasses breakdowns

throughout the patient care

continuum; particularly,

issues with reporting

results (including incidental

findings) to patients or their

physicians

Increasingly noted over the

past few years


F O C U S O N C L I N I C A L J U D G M E N T

Various factors can contribute to clinical judgment issues, particularly in diagnosis-related claims. The primary issue is

inadequate patient assessment, which includes:

All Allegations

Diagnosis-Related Only

• Lack of access to patients’ prior medical records, including

family history• Failure among providers to share subtle patient changes

• Inadequate patient reevaluation processes, particularly in

relation to abnormal vital signs. • Inadequate EHR system functionality/integration, which

prevents effective compilation of patient information

80%

70%

60%

50%

40%

30%

20%

10%

0%Inadequate

Assessment

Failure to

Order Consult

Failure to Order

Diagnostic Test

Narrow

Diagnostic

Focus

Selection/

Management of

Treatment

Misinterpretation

of Diagnostic Test

% o

f A

lleg

atio

ns W

ith

Th

is R

isk F

acto

r

65%

73%

39%

46%

38%

52%

37%

55%

24%

19%

14%

19%

Learn More: A study by The Sullivan Group of 90,000 high-risk ED patients showed that 10% had at least one very abnormal vital sign. Of these patients, 16% were discharged without a reevaluation.

Source: Ten reasons your emergency department may not be as safe as you think it is. The Sullivan Group. (2006).


35%

30%

25%

20%

15%

10%

5%

0%

29%

33%

16%

11%

Among Providers Between Providers

and Patients/Families

All Cases Diagnosis-Related Only

Consider the patient with resolving chest pain who is being discharged with an appointment to see a cardiologist in 2 days.

Emphasize to the patient the importance of keeping that appointment, and ask the patient to state his or her intent to see

the cardiologist as scheduled.

F O C U S O N C O M M U N I C AT I O N%

of A

lleg

atio

ns W

ith

Ris

k F

acto

r

Claims involving communication issues

with patients have several recurring

themes, including incomplete discharge

instructions, poor patient

comprehension of instructions, and

provider failure to adequately document

both issues. Also, patient noncompliance

is an increasingly noted issue that is

greatly influenced by the above factors.

Communication issues in an

emergency setting are primarily

related to provider-to-provider

interactions and information

sharing. Factors that can

negatively affect communication

among providers include:

• EHR systems that limit

interactions among providers

and don’t allow easy viewing of

other providers’ notes

• Breakdowns in transitions of

care (handoff) procedures

during shift changes


O T H E R T O P R I S K FA C T O R S

To better illustrate the impact of failures in the diagnostic test reporting process, consider lung cancer diagnoses. Two-thirds of claims

associated with these diagnoses involved a critical test result that was identified but not reported to the patient. One-fourth of these claims

involved suspected disease incidental findings not reported to the patient. The remaining 8% of these claims involved misread tests, even

when the suspicion for the diagnosis existed.

D O C U M E N T A T I O N

A D M I N I S T R A T I V E

C L I N I C A L S Y S T E M S

• Insufficient documentation within patient records

• Lack of consistent documentation among providers

• Inappropriate documentation that is not pertinent to the patient’s care

• Failure to follow protocols for addendums, corrections, and alterations to records

• Key concerns: Documenting clinician’s rationale for inclusion/exclusion of differential

diagnoses and treatment decisions

• Lack of, or failure to adhere to, policies and procedures

• Physician coverage and staffing issues

• Unavailability of equipment

• Lack of staff training and education

• Key concerns: Triage, medication protocols, radiology over-read timing, staff

supervision, reassessment of patients who have been admitted but not transferred

from the ED

• Issues with care coordination during the emergency visit, including (a) lack of interaction

between systems for tracking test results, and (b) an inadequate process for obtaining

consults

• Key concerns: Tests results received postdischarge, incomplete discharge instructions,

primary care providers unaware of patient visits, and reassessment of patients who have been

admitted but not transferred from the ED


C L I N I C A L J U D G M E N T A N D

C O M M U N I C AT I O N R I S K S T R AT E G I E S

C L I N I C A L J U D G M E N T

C O M M U N I C A T I O N

• Implement comprehensive test tracking and referral tracking procedures that include

protocols for complete review of imaging studies, patient follow-up, and documentation.

• Thoroughly screen patients for risk factors, atypical presentations, and associated

symptoms to avoid a narrow diagnostic focus.

• Utilize evidence-based guidelines for MIs, CVAs, intracranial bleeds, etc. Consider the

use of clinical decision support aids and group decision-making to support clinical

reasoning.

• Ensure timely ordering of tests and consultations to prevent problems associated with

ruling out or documenting abnormal findings.

• Define and implement a detailed process for patient handoffs, including expectations for

verbal and written communication. Audit for compliance with the policy.

• Ensure prompt communication and documentation of relevant findings from

consultations and referrals.

• Thoroughly review the medical record at each patient encounter to stay informed of the

most recent clinical information.

• Provide patients/caregivers with written and verbal instructions related to their treatment

plans and follow-up care. Make sure written instructions are at an appropriate reading

level.

• Utilize comprehension techniques, such as “teach-back” to ensure patients fully

understand instructions.

• Consider implementing follow-up calls with patients/caregivers to reinforce compliance

with treatment plans.


D O C U M E N TAT I O N , A D M I N I S T R AT I V E , A N D C L I N I C A L

S Y S T E M S R I S K S T R AT E G I E S

Review patient records to ensure that information is complete, concise, accurate, and consistent.

Verify that documentation supports clinical rationale, diagnosis, and treatment decisions.

Provide thorough and timely documentation of each patient’s condition at discharge.

Adhere to processes for following up on radiology discrepancies and communicating test results received after discharge.

Be aware of and adhere to supervisory requirements for medical residents, advanced practice providers, and scribes.

Use team drills and situational simulations to improve teamwork between all providers in the ED.


A patient presented to an ED

complaining of acute onset of back,

abdominal, and lower chest pain, as

well as difficulty walking. A toxicology

screen was positive for illicit drug use.

A teleradiologist determined that a

preliminary chest CT scan of the

patient was normal. As a result, the

emergency physician concluded that

the patient’s symptoms were related to

drug withdrawal and discharged the

patient. An on-staff radiologist

provided an over-read of the CT scan

postdischarge and identified increased

density at T8–T9, attributed to

degenerative disc disease. However,

the patient was not notified to seek an

additional consultation.

CASE SUMMARY: FAILURE TO DIAGNOSE EPIDURAL ABSCESS

Risk management issues for this claim:

Failure to establish a differential diagnosis when all clinical information was available

Ineffective communication among the telemedicine radiologists, the on-staff radiologists,

and the emergency physicians

Misinterpretation of diagnostic studies

Three days later, the patient

presented again to the same ED with

cough, chill, body aches, and a fever.

Lab work revealed an elevated white

blood cell count and sedimentation

rate and positive toxicology; a chest

X-ray revealed pulmonary infiltrates.

An abdominal CT scan, which was

read by another teleradiologist,

showed degenerative spine changes.

The emergency physician diagnosed

the patient with pneumonia and drug

withdrawal, and the patient was

discharged with an antibiotic

prescription. The over-read of the

abdominal CT scan by a second on-

staff radiologist noted pulmonary

infiltrates, but made no mention of

spinal changes.

One day later, the patient developed

numbness in his lower extremities and

presented to a different ED, where

MRI revealed an epidural abscess at

T7–T10. The patient developed

permanent lower extremity paralysis

despite treatment.

The teleradiologists involved in the

patient’s first two visits were not aware

of the patient’s complaints of back

pain and difficulty walking; they

indicated that lack of information

influenced their conclusions after

reading the films. They relied on the

facility’s radiologist and emergency

physician to render a final diagnosis.

The on-staff radiologist at the second

ED visit was not aware of the patient’s

previous admission to the ED with a

history of back pain; he noted that an

MRI would have been warranted at

that point.


C L A I M S I N T H E E M E R G E N C Y D E PA R T M E N T: O T H E R

R E S P O N S I B L E S E R V I C E S

Emergency Nursing Radiology Other

80%

70%

60%

50%

40%

30%

20%

10%

0%% o

f C

ase

s b

y P

rim

ary

Re

sp

on

sib

le S

erv

ice

Coordination of care among all providers in the ED is critical; it provides a safety net for the patients. Any failures in the system of care can

result in allegations of malpractice against the emergency medicine physician, even if he or she is not named as the primary responsible service.

Claims associated with the ED setting identify an emergency medicine physician as the primary responsible service about

75% of the time. However, as seen below, nursing and radiology providers also are noted as the primary responsible

service in 7% and 4% of claims, respectively. The “other” category includes other consulting physicians, such as surgeons

and medicine specialists (e.g., neurologists and cardiologists).

Patient falls resulting in fractures, triage-related issues (including incorrect triage level designation and waiting room

monitoring), and problematic IV-related procedures were the allegations most commonly attributed to nursing staff. Failure

to diagnose fractures was the most common allegation against radiologists.

73%

7%4%

16%

Risk Strategies

• Enhance systems and processes that support open lines of communication

and more opportunities for physicians, nurses and consulting physicians to

interact.

• Develop documentation standards to reduce inconsistencies between nurse

and physician notes, and requirements for complete documentation of

critical information.

• Implement a well-designed process to streamline communication of critical

results to patients, including results received postdischarge.


I M P O R TA N T R I S K M I T I G AT I O N S T R AT E G I E S

T R I A G E • Ensure rapid evaluation, reevaluation, and use of symptom-based protocols.

P A T I E N T

S A T I S F A C T I O N

C L I N I C A L

J U D G M E N T

• Communicate with patients, including about wait times, and apologize for delays.

• Develop a procedure for managing and responding to patient complaints.

• Gauge patient satisfaction through the use of surveys.

• Reconsider differential diagnoses of returning patients, patients who have no

signs of improvement, and patients who are intoxicated or seeking drugs.

• Prior to discharge, reevaluate patients who have abnormal vital signs/labs.

D O C U M E N T A T I O N • Describe rationale for inclusion/exclusion of differential diagnoses.

• Ensure consistency in the notes of physician and other providers.

• Make a thorough notation of each patient’s condition at discharge.


I M P O R TA N T R I S K M I T I G AT I O N S T R AT E G I E S ( C O N T I N U E D )

P A T I E N T

E D U C A T I O N

• Consider patients’ health literacy skills, and provide information in layman’s terms.

• Use comprehension techniques, such as the “teach-back” method.

T E S T T R A C K I N G

A N D F O L L O W - U P

C R O S S - T E A M

T R A I N I N G

• Focus on radiology discrepancies, test results received after discharge, and

the patient callback process.

• Ensure training includes nurses, advanced practice providers (such as nurse

practitioners and physician assistants), hospitalists, radiologists, etc.

• Include cross-team training as part of quality improvement programs.


In all major allegation categories, emergency

medicine is among the specialties that have

the highest percentage of claims involving high

clinical severity outcomes. High-severity

outcomes include death or permanent injury —

and, as one would expect, these claims have

large payments.

Claims involving spinal abscesses,

pneumonia, sepsis, spinal fractures, CVAs,

aortic aneurysms, PEs, traumatic

intracranial bleeds, appendicitis, and

cancer — along with MIs — account for

nearly 70% of the dollars paid on

diagnosis-related claims.

Diagnosis-related allegations account for the

majority of emergency medicine claim volume

(64%) and claim-related payments (82%).

Medication-related allegations represent a

relatively small volume of emergency

medicine claims; however, claims related to

narcotic overdose appear to be on the rise.

MIs are the most frequent individual diagnosis

cited in the emergency medicine diagnosis-

related allegations. However, infections as a

broad class represent the largest subcategory

of diagnosis types in these allegations.

In some circumstances, nurses,

radiologists, or other types of providers are

identified as the primary responsible

service in emergency medicine claims, but

most claims in the ED setting name

emergency physicians as the primary

responsible service.

K E Y P O I N T S


A N O T E A B O U T M E D P R O G R O U P D ATA

MedPro Group has entered into a partnership with CRICO Strategies,

a division of the Risk Management Foundation of the Harvard Medical

Institutions. Using CRICO’s sophisticated coding taxonomy to code

claims data, MedPro Group is better able to identify clinical areas of risk

vulnerability. All data in this report represent a snapshot of MedPro

Group’s experience with emergency medicine claims, including an

analysis of risk factors that drive these claims.

D I S C L A I M E R

This document should not be construed as medical or legal advice. Because the facts applicable to

your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your

attorney or other professional advisors if you have any questions related to your legal or medical

obligations or rights, state or federal laws, contract interpretation, or other legal questions.

MedPro Group is the marketing name used to refer to the insurance operations of The Medical

Protective Company, Princeton Insurance Company, PLICO, Inc. and MedPro RRG Risk Retention

Group. All insurance products are underwritten and administered by these and other Berkshire

Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is

based upon business and regulatory approval and may differ between companies.

© 2016 MedPro Group Inc. All rights reserved.

Documents

Emergency Medicine Malpractice Claims Data & Risk Analysis€¦ · 2 0 1 6 Malpractice Claims Data & Risk Analysis 2 This publication contains an analysis of the aggregated data from