Using Malpractice Claims to Help Physicians Avoid Diagnostic Mistakes, Delays
A doctor assumes a patient's recurrent cough is a respiratory infection and doesn't order a chest X-ray, missing a deadly lung cancer. A 40-year-old woman dies of a rare blood disease after her abnormal lab test falls through the cracks. A man dies from an obstructed bowel after different doctors treating him fail to share information about his acute abdominal pain.
Medical professionals are finding lessons in these and other past malpractice cases. By analyzing the breakdowns in care that led to missed, delayed or incorrect diagnoses, insurers and health-care providers are developing programs to avert mistakes. For example, some doctors are using electronic alerts and reminders to order tests, follow up on lab reports and close the loop with specialists to whom they refer patients.
Diagnostic errors are the leading cause of malpractice suits, accounting for as many as 40% of cases and costing insurers an average of $300,000 per case to settle, studies of resolved claims show. Peter Pronovost, a patient-safety researcher at Johns Hopkins University, estimates that diagnostic errors kill 40,000 to 80,000 hospitalized patients annually, based on autopsy studies over the past four decades.
Studies of malpractice-claims data show that diagnostic errors often don't have a single cause. There are often at least three breakdowns that lead to missed or delayed diagnoses. Patients play a role as well: They may not seek care on a timely basis, fail to show up for tests or fail to follow instructions, such as not fasting before a blood test or not adequately emptying the bowels before a colonoscopy.
One concern is that using claims data to educate doctors will lead to more "defensive medicine," in which doctors order more tests and procedures than needed to protect themselves against malpractice suits. In a study in the June Archives of Internal Medicine, 91% of physicians surveyed reported that doctors practice defensive medicine; the majority of physicians also agreed that legal protections against unwarranted malpractice suits are needed to decrease the unnecessary use of diagnostic tests.
"Medicine is often a crapshoot and an odds game," and doctors can miss a diagnosis even if they adhere to guidelines on when to order a test, says Dr. Pronovost. Reducing diagnostic errors, he says, will require a focus on larger system failures, such as preventing lab results from getting lost and developing checklists to help doctors distinguish between, say, a "low-risk" headache and a "high-risk" headache.
Diagnostic mistakes most often involve cancer, with breast cancer the most commonly missed or delayed diagnosis. Last year, a jury awarded $2.5 million in a case brought by Barbara Glasow, who, before she died in May 2009, sued St. Luke's Hospital in Bethlehem, Pa., claiming the hospital and one of its doctors failed to diagnose her breast cancer in May 2004, when she came to see him for a lump on her chest. According to the suit, the doctor told her it was a cyst. By February 2005, it had broken in two and began to bleed. A biopsy determined that it was breast cancer. Her attorney, Steven Margolis, is pursuing the award, plus interest, totaling $2.9 million on behalf of her family. St. Luke's is appealing the case, and the hospital declined to comment.
Oakland, Calif.-based managed-care giant Kaiser Permanente also uses malpractice-claims data for educational purposes. But it relies on close tracking and follow-up of patients with abnormal test results to avoid missed diagnoses, says breast cancer surgeon Susan Kutner. Over the past 15 years it has identified 420,000 abnormal biopsies and 320,000 abnormal mammograms. As a result, 450 patients were found to have a new or recurrent cancer or an abnormal biopsy "who would not have been found if we did not bring them in proactively," Dr. Kutner says.
The Veterans Health Administration is developing programs to help doctors more closely follow up on abnormal lab results, which it delivers through an electronic medical record system. VA studies show that doctors are often overwhelmed by alerts and may not follow up, even when an alert says the test is abnormal. Hardeep Singh, chief of the health quality and policy program at the Houston VA research center, says its studies also show that if both a primary-care doctor and a specialist get test results, each assumes the other will follow up.
"Patients may think that if something was wrong, my doctor would have told me," says Dr. Singh. "But no news is not necessarily good news, and patients need to be empowered to follow up on their lab results and participate more actively in their care."
While malpractice claims represent only a fraction of all medical cases, "they are reflective of deeply rooted problems that are much more widespread in health care," says Robert Hanscom, vice president of loss prevention and patient safety for Crico/RMF, a malpractice insurer that covers Harvard University-affiliated hospitals and doctors. Mr. Hanscom says cases linked to diagnostic errors appear to be on the rise as primary care doctors, struggling with heavy case loads, take shortcuts or don't act on their patient's symptoms. Also hospitals are concerned about trial lawyers who may seek high monetary damages.
Of 1,137 malpractice cases between 2005 and 2009, diagnostic errors accounted for 26% of Crico/RMF's claims. But among the 456 "high severity" cases that resulted in serious patient harm or death, nearly half were diagnostic errors.
"People may show up with a series of symptoms or complaints that aren't taken seriously at the moment, or a physician...doesn't see the complaint as something new to be concerned about," says Ann Louise Puopolo, a nurse and patient-safety program director at Crico/RMF. For example, in missed or delayed colorectal cancer cases, patients often showed up with some kind of rectal bleeding, a usual sign that further testing is needed, but was not performed, says Ms. Puopolo.
Crico/RMF is offering continuing medical-education credits to doctors who study its analysis of the closed malpractice cases. And in a program it is co-sponsoring at Brigham and Women's Hospital in Boston, researchers are working with 16 primary-care practices in Massachusetts, using lessons from the claims to help them avoid common pitfalls like failing to consider that a patient with persistent symptoms might need a diagnostic test, and failing to follow up on abnormal test results when they come in.
"These errors may be less visible and dramatic than getting the wrong leg cut off, but a delay in diagnosis can adversely affect a patient's long-term outcome," says Gordon Schiff, associate director of patient-safety research at Brigham and Women's. Malpractice cases "let us drill down and learn deeper lessons, like what could have been done differently," Dr. Schiff says.
By Laura Landro, The Wall Street Journal
Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP
