Wednesday, October 16, 2013

Where malpractice is most likely

David Hyman and William Sage note in an JAMA editorial :

Most people’s mental map of medical malpractice is hospital centric. Hospitals are where highly trained specialists provide risky, technology-intensive treatments to patients with the most serious and complicated illnesses. Diagnostic and therapeutic decisions must be coordinated to avoid disaster, but care is provided by an ever-shifting array of physicians, nurses, and other health care professionals. The possibility of things going catastrophically wrong is pervasive. When a bad outcome occurs, the hospital is also the primary repository of information about what happened and who might be responsible, as well as a large and well-insured defendant. An inpatient medical record provides “one-stop shopping” for any plaintiffs’ lawyer who is deciding which physicians to sue.

Then they go on to explain why the mental map is wrong.  While obstetrics, neurosurgery, orthopaedics, and thoracic surgery remain the in-hospital specialties that tend to generate the highest rates of malpractice asserts, the doctors that are often in just as much jeopardy are the ones working in primary care office practices.  Here's the summary of the recent article to which Hyman and Sage refer:

Malpractice risk in outpatient primary care is increasingly under scrutiny. This study screened malpractice claims from two Massachusetts insurers and found that those from outpatient primary care settings were more likely to be settled or found in favor of the plaintiff compared with those from other practice settings. Similar to previous research, claims related to missed and delayed diagnoses were most frequent, and the most common disease involved was cancer, followed by cardiovascular disease. The accompanying editorial argues that primary care settings will become increasingly important for malpractice claims with the advent of patient-centered medical homes and accountable care organizations, which shift a larger proportion of medical care to the outpatient primary care setting. The authors note a high prevalence of failure-to-diagnose claims and recommend further emphasis on diagnostic safety.

The most important finding, I believe, is that the failure-to-diagnose claims do not result from physician diagnostic errors.  They come from failures in routine but yet high-volume outpatient office processes.  Here's an typical scenario: A test is ordered by the PCP.  It either does not get scheduled; or it gets scheduled and the test result is not returned; or the test result is returned, but it is not seen and is therefore not acted upon by the PCP. The patient next shows up with advanced cancer.

For those who are skeptical of using Lean or other work-flow improvement approaches, think again, as they can be extremely effective in fixing this kind of error.


Barry Carol said...

It seems that more widespread use of electronic medical records would be very helpful in catching test results not recorded in the chart or acted upon. Ultimately, these records need to be interoperable so all providers can have access to them when and as needed.

I also think we need to provide doctors with strong safe harbor protection from failure to diagnose lawsuits if they can show that they followed evidence based guidelines and protocols where they exist. For example, if a PSA was not ordered because the guidelines don’t call for it and the patient is later diagnosed with prostate cancer, there should be a prompt determination that there is no basis for a lawsuit. With such protection, perhaps there would be a meaningful decline in defensive medicine.

Naomi Kaufman Price said...

From Facebook:

Dx errors run under the radar but are huge, huge & run the gamut. As you rightly note, lots of "fall through the cracks" things. Evidence-based testing takes you only so far, as the evidence can have many asterisks, eg family history, race, actual symptoms -- to say nothing of the grade of the evidence and patient preference. (Can you tell that gray is my favorite color?)