Hospitalists face unique medical malpractice risks—they manage high-acuity patients, have limited access to patients’ medical histories, and often receive patients with serious conditions. And, patients are presenting to hospitals with diagnoses (like spinal epidural abscess) that have historically been rare but are now appearing in malpractice claims with increasing frequency.
To reduce risks for hospitalized patients, we need to understand where patients are vulnerable, what systems can fail, and whether there are areas where physicians have knowledge deficits.
A new study of 464 closed medical malpractice claims against hospitalists insured by The Doctors Company highlights the particular risks doctors face when practicing hospital medicine as well as how system failures and processes result in patient harm. The study covered claims closed from 2007 to 2014, regardless of the outcome of the claim, in order to fully understand what motivates patients to sue hospitalists and to identify the greatest patient safety risks. In addition to determining the most common patient allegations, expert physicians reviewed the data to determine the factors that caused patient injury.
The need for accurate and timely diagnosis
The top patient allegation was diagnosis related—either failed, delayed, or wrong diagnosis. Expert physician reviewers noted that 35% of cases resulted from an inadequate initial assessment, consequently, decreasing the chance that the hospitalist would arrive at the correct diagnosis.
In one case, a 20-year-old female presented to the ER with fever, chills, and pain radiating to her back from her right side. She was admitted, and pulmonary and infectious disease consults were ordered. D-dimer levels were elevated. Her chest x-ray showed a right lower lobe infiltrate. The patient was diagnosed with pneumonia and started on antibiotics by the hospitalist. Subsequently, she complained of shortness of breath and periods of confusion. Her O2 saturation levels ranged from 86%-89%. She later collapsed and died. The cause of death was pulmonary embolism (PE). Expert reviewers concluded that the elevated D-dimer levels along with other factors indicated possible venous thrombosis and risk for PE. Failure to order appropriate diagnostic tests and to consider available clinical information were identified as factors contributing to this patient’s death.
These strategies can help reduce the risk of diagnostic delays or errors:
- Patient complaints are the first source of information to assist the hospitalist in arriving at a correct diagnosis. It is essential to take a detailed medical history and conduct a thorough patient assessment.
- Timely diagnosis often depends on how quickly diagnostic studies are performed and interpreted. If a differential diagnosis has the potential for serious sequelae or death, alert other specialists as early as possible of the potential need to involve them in the patient’s care.
- Some diagnoses, like spinal epidural abscess, have historically been rare but are now appearing in medical malpractice claims with increased frequency. The symptoms of spinal epidural abscess now have a recognized pattern. When those patterns are identified (neck or back pain, loss of neurological control or sensation, and fever), an MRI should be ordered STAT to confirm the diagnosis. Surgeons should be consulted early in the diagnostic process to expedite treatment and preserve neurological function.
Why strong team communication lowers risk
The second most common factor contributing to patient injury was communication among providers—appearing in 23% of claims. For example, important information was not communicated to other healthcare practitioners. In some cases, nurses identified patients who were at risk for deep venous thrombosis (DVT) or PE or who exhibited changes in neurological status, but they failed to notify a physician. Other cases involved physicians who failed to see or find important clinical information documented in the medical record and, therefore, were unaware of changes in the patient’s condition or unaware of alterations to medications, diet, and therapies. These types of oversights resulted in lack of coordination of care and, in some situations, caused harm.
A case that illustrates this issue involved a 49-year-old male who was admitted with chest pain, headache, back pain, and numbness and tingling in his lower extremities. Blood pressures were 154/53 mmHg in the right arm and 117/56 in the left arm. The nurse failed to document these abnormal blood pressure findings in the medical record or to call them to the attention of the admitting hospitalist. The patient was discharged but later found unresponsive at home and died. An autopsy revealed aneurysmal dilatation of the ascending aorta with mediastinal hemorrhage secondary to an aortic dissection. Lack of communication between nursing and the hospitalist was identified as a critical factor in the patient’s death.
Hospitalists are on the frontline of patient care and often coordinate the care provided by other specialists on a team. Communication and coordination are essential parts of the hospitalist’s role. These tips can help:
- Be accessible and responsive to nurses. Build rapport. Don’t create an environment in which nurses hesitate to reach out because they are afraid of the response.
- Communicate concerns and fears for specific patients when handing off to fellow hospitalists. Provide advanced warning about patients who have confusing presentations or deteriorating conditions.
- Build rapport with the other physician specialists you contact for patient referrals. Stay engaged after the other specialists have joined the case. Clarify your responsibility to coordinate care with the rest of the clinical team, including the specialists.
- Review all documentation to ensure that you are aware of all consultation reports, consultant orders, and any subtle changes in the patient’s condition that nursing has noted.
What patients can do
Patients can also play a key role in ensuring safe and effective care. Patient factors—such as noncompliance in treatment plans—played a role in 12% of claims. As a patient, you should:
- Provide honest and complete answers to physician questions
- Ask questions about any information that is not understood
- Make sure you understand the role of the hospitalist compared to the role of your primary care physician
- Comply with the treatment plans, follow-up appointments, testing regimens, and medication plans
- Understand the risks of the medications you are taking
- Contact your physician if you are experiencing any side effects from medication
The Doctors Company hopes that physicians will use this data to prompt deeper review of the processes and procedures found in the hospitals where they work. This data can prompt development of quality measures to be monitored to determine if problems identified in this study could happen in each organization.
To read the full study, including the full list of patient allegations and factors leading to injury, more case studies, and additional risk mitigation tips, visit www.thedoctors.com/hospitaliststudy.
This post was sponsored by The Doctors Company, the nation’s largest physician-owned medical malpractice insurer.