Study Examines Causes of High-severity Malpractice Cases

July 16, 2019 10:27 am News Staff

Slightly more than one out of three cases of medical malpractice that result in death or permanent disability can be linked to inaccurate or delayed diagnosis. And of those cases, about three-quarters can be traced to diagnostic errors involving just three types of conditions: cancer, vascular events and infection.

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That's according to a study published online July 11 in the peer-reviewed journal Diagnosis.(www.degruyter.com)

The research was funded by the Society to Improve Diagnosis in Medicine through a grant from the Gordon and Betty Moore Foundation. The AAFP supports the SIDM through its work with the Coalition to Improve Diagnosis,(www.improvediagnosis.org) a collaboration of more than 50 health care and patient advocacy organizations convened and led by the SIDM.

"It is not just inconvenient to have a wrong or delayed diagnosis," said study lead author David Newman-Toker, M.D., Ph.D., director of the Johns Hopkins Armstrong Institute for Patient Safety and Quality's Center for Diagnostic Excellence, in a news release.(www.improvediagnosis.org) "For many patients, misdiagnosis causes severe harm and expense, and in the worst cases, death."

Story Highlights
  • More than one out of three cases of medical malpractice that result in death or permanent disability can be linked to inaccurate or delayed diagnosis, according to a study published online July 11 in the peer-reviewed journal Diagnosis.
  • Researchers from the Johns Hopkins University School of Medicine analyzed more than 55,000 malpractice claims reported to the Controlled Risk Insurance Company's Comparative Benchmarking System database from 2006-2015.
  • They found that of diagnostic errors that caused the most harm, nearly three-quarters could be attributed to just three types of conditions: cancer, vascular events and infection.

Study Details

Researchers from the Johns Hopkins University School of Medicine in Baltimore analyzed more than 55,000 malpractice claims reported to the Controlled Risk Insurance Company Ltd.'s Comparative Benchmarking System database from 2006-2015 to identify diseases or conditions that accounted for most serious misdiagnosis-related harms (morbidity/mortality). Diagnostic error cases isolated from CRICO's CBS database represented 28.7% of all U.S. malpractice claims.

Diseases were grouped according to the Agency for Healthcare Research and Quality's Clinical Classifications Software, which aggregates International Classification of Diseases diagnostic codes into clinically sensible groupings.

Specifically, the researchers analyzed claims for the so-called Big Three -- vascular events, infections and cancers -- which, according to previous research, collectively account for most of the morbidity and mortality attributable to diagnostic errors. High-severity harms were defined by scores of 6-9 (serious, permanent disability, or death) on the National Association of Insurance Commissioners Severity of Injury Scale. Of the malpractice claims attributable to diagnostic error, researchers reviewed underlying disease states to identify patterns of misdiagnosis.

They found that the Big Three accounted for 74.1% of the diagnostic errors that caused the most harm, with the breakdown as follows: cancer (37.8%), vascular events (22.8%) and infection (13.5%). The most frequent disease in each respective category was lung cancer, stroke and sepsis.

Overall, these severe cases resulted in $1.8 billion in malpractice payouts during a 10-year period.

According to the authors, this research confirms that inaccurate or delayed diagnosis remains the most common, catastrophic and costly type of medical error in closed malpractice claims.

"If we're going to reduce serious harms from medical errors, major strides must be made to improve diagnostic accuracy and timeliness," said Newman-Toker, who also is SIDM president, in the release. "This study shows us where to focus to start making a difference for patients. It tells us that tackling diagnosis in these three specific disease areas could have a major impact on reducing misdiagnosis-related harms."

What Needs to Change?

According to the news release, the researchers contend that improving diagnosis isn't solely the responsibility of physicians. Instead, it will require systemwide efforts that include involving patients and their families.

They also noted that research and quality improvement efforts should focus on interventions in the specific practice settings where the harm occurs, "such as stroke in the emergency department, sepsis in the hospital, and lung cancer in primary care."

"This work showcases that myriad factors contribute to missed and delayed diagnosis and highlights the need for further collaboration across the health care system to significantly improve diagnosis and ensure the best possible outcomes for patients," said SIDM CEO and co-founder Paul Epner, in the release. "The complexity of the diagnostic process and the collaborative approaches needed to improve accuracy mean change will not occur overnight."

One effort to address the multifaceted problem of diagnostic error is SIDM's ACT for Better Diagnosis(betterdiagnosis.org) initiative, which seeks to improve the diagnostic process by calling on Coalition to Improve Diagnosis members to identify and disseminate practical steps to better ensure diagnoses are Accurate, Communicated and Timely. As AAFP News reported last September, the Academy supports this effort.

Finally, the study authors said future research should seek to better clarify the relationship between harms reported in malpractice claims and harms that occur in real-world clinical practice, particularly with respect to cancer, which appears to be overrepresented in claims data.

Related AAFP Efforts

For its part, the AAFP provides evidence-based guidance to facilitate accurate and timely diagnoses through its development of clinical practice guidelines, clinical preventive services recommendations and Choosing Wisely campaign recommendations.(www.choosingwisely.org)

American Family Physician and familydoctor.org(familydoctor.org) also cover the AAFP's Choosing Wisely efforts and provide additional resources to facilitate discussions between family physicians and patients regarding appropriate tests and treatments.

Related AAFP News Coverage
Fresh Perspectives: Cloudy With a Chance of Misdiagnosis
(10/6/2015)

Fresh Perspectives: Eye on the Ball: Overreliance on EHRs Can Bring Disaster
(9/21/2015)