JournalYOUR SOURCE FOR PROFESSIONAL LIABILITY EDUCATION AND NETWORKING

April 2015 Vol. XXVIII Number 4

PLUS Journal ReprintProfessional Liability Underwriting Society5353 Wayzata Blvd., Suite 600Minneapolis, MN 55416-4758phone 800.845.0778 or 952.746.2580www.plusweb.org

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April 2015 PLUS Journal 1

Paul A. Greve, Jr., JD, RPLU, is Executive Vice President at Willis Health Care Practices. He can be reached at paul.greve@willis.com.

P. Divya Parikh isDirector of Research& Risk Management atthe PIAA. She can bereached at dparikh@piaa.us.

Diagnostic Error: Pervasive and PersistentBy Paul A. Greve, Jr., JD, RPLU & P. Divya Parikh MPH

$0  

$75,000  

$150,000  

$225,000  

$300,000  

$375,000  

$450,000  

0  

2,500  

5,000  

7,500  

10,000  

12,500  

15,000  

Improper  performance  

Errors  in  diagnosis   Failure  to  supervise  or  monitor  case  

Failure  to  recognize  a  complica@on  of  

treatment  

Medica@on  errors  

Avg  Inde

mnity  

Closed

 Claim

s  

Closed  Claims   Avg  Indemnity  

Diagnostic Error second by number of closed claims; Highest by average indemnity payment.

Exhibit 1

The problem of diagnostic error has gotten more attention than ever over the last ten years in patient safety and medical literature. There are hundreds of articles on a problem that is both pervasive and persistent. The primary care specialties have been principally involved by virtue of the very nature of their practice.

But closed claim studies by the PIAA have shown that the problem occurs at a significant rate in surgical and other specialties as well. For example, in the time frame of 2008-2012, data from

the PIAA Data Sharing Project (DSP) reported that of all the chief medical factors reported, diagnostic errors accounted for the second highest reason for claims and resulted in the highest average indemnity payments (See Exhibit 1). Additionally, surgical specialties were named in 9% of all closed claims reporting diagnostic error; hospitalists’ were named in 22%; advanced practice providers were reported in 24%. Non-surgical specialties (including primary care specialties) were reported in 31% of medical professional liability claims

naming diagnostic error as the chief medical factor in the claim (See Exhibit 2).1

In closer review of the diagnostic error MPL claims reported to the DSP for this five-year period, radiologists were most often named in claims, and claims related to cancer were the top medical conditions (breast, lung, and colorectal cancer specifically). Obstetricians/gynecologists were reported to have the highest indemnity payments reported for diagnostic error. And diagnostic error in cardiac/cardiorespiratory

2 Professional Liability Underwriting Society

conditions saw the top number of claims reported for this time period followed by breast cancer, lung cancer, acute myocardial infarction/heart attack, and colorectal cancer (See Exhibit 3).

Health care delivery in the United States has increasingly shifted to outpatient settings. One study published in 2014 concluded that

the frequency of diagnostic error annually for adults seen in outpatient settings was 5%. The authors urged more efforts to measure diagnostic errors and reduce them.2 Interestingly, in an article published in 2012 in which 1,000 primary care physicians were surveyed, those participating reported that more than 5% of their patients were “difficult to diagnose”.3

An excellent article in the ASHRM Journal in 2014 discussed the challenges of patient safety in diagnosis. These are “…to identify and measure diagnostic errors” and “to reduce both the frequency and severity of errors.” Prevention of diagnostic error has the potential to improve with such new tools as decision-making support software and high-risk triggers. The author called diagnostic errors “both frequent and dangerous”.4

Historically, diagnostic error claims usually involved only physician defendants. The physician defendant’s personal medical professional liability policy was responsible for any payment of indemnity and that was usually no more than $1M per claim. Hospitals and health systems were less frequently culpable in those claims scenarios, absent a system error or failure to communicate by a hospital employee. As physicians, especially primary care physicians, have moved more often into hospital employment the full limit of the hospital’s policy is now potentially exposed for a malpractice claim of diagnostic error. That is just one more reason for hospital patient safety and risk management programs to focus on this significant issue. Doing so will save lives and save money.

31%  

69%  

Non-Surgical

9%  

91%  

Surgical

22%  

78%  

Hospitalist

24%  

76%  

Advanced Practice Providers*

*CRNA, PA, SA, NP, Certified Midwife

Diagnostic Error

Other CMF

Exhibit 2

$0  

$150,000  

$300,000  

$450,000  

$600,000  

0  

200  

400  

600  

800  

Cardiac  or  cardiorespiratory  

arrest  

Breast  cancer   Lung  cancer   AMI   Colorectal  cancer  

Avg  inde

mnity  

Closed

 Claim

s  

Closed  Claims   Avg  Indemnity  

Cardiac/Cardiorespiratory arrest most prevalent by closed claims; Cancer conditions dominated top diagnostic error claims.

Exhibit 3

Endnotes

1 PIAA Data-Sharing Project, 2014.

2 Singh, Hardeep, et al. ‘The frequency of diagnostic errors in outpatient care: estimations from the three large observational studies involving US adult populations. BMJ Qual Saf. April 2014. http://qualitysafety.bmj.com.content/early/2014/4/05/05/bmjqs-2013-002627.full (accessed February 11, 2015).

3 Sarkar, U et al. “Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians”. BMJ Qual Saf 2012; 21: 641-648.

4 Groszkruger, Dan. “Diagnostic error: untapped potential for improving patient safety?” Journal of Healthcare Risk Management 2014; Vol. 34; No.1. 38-43.