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An Analysis of Internal Medicine Malpractice Claims

We reviewed 369 consecutive closed internal medicine claims from 2000 through 2007 to identify events that place internists at risk for a malpractice claim. These claims are from The Doctors Company’s Midwest Region and include the subspecialties of cardiology, gastroenterology, hematology, infectious disease, and immunology. Because we performed this analysis to identify events leading to malpractice claims, we included claims without professional negligence and those without payments of indemnity.

Overview of Claims
We found that 58 percent of the allegations in these claims were related to diagnosis, 23 percent were related to medical treatment, 9.5 percent were related to improper medication management, 2.2 percent involved ordering errors, 1.6 percent involved patient monitoring, and 5.7 percent were miscellaneous.

The 58 percent of claims alleging diagnosis-related negligence are subdivided into those resulting from failure to make the correct diagnosis and those resulting from diagnostic delay (Table 1).

The 23 percent of claims that alleged negligence related to medical treatment are subdivided into seven categories (Table 2).

A total of 9.5 percent of claims alleged medication-related negligence, and 58 percent of these claims involved medication management.

A total of 2.2 percent of claims alleged negligence resulting from ordering errors. Of these claims, 75 percent resulted from failure to order, and 25 percent involved a wrong dose.

Repetitive Clinical Events
When the clinical summaries of these 369 claims were reviewed, the events that led to the claim appeared random and were nonrepetitive in 239 claims. Further analysis of these claims was not pursued because there were no patterns from which generalizations could be drawn. However, the remaining 130 claims contained repetitive errors, system failures, and clinical events. Within this subset, 67 percent of the allegations were related to diagnosis, 21 percent were related to improper medication management, 9 percent were related to improper management and/or treatment, and 3 percent involved patient monitoring.

1.	Diagnosis-Related Claims: The 67 percent of repetitive claims that alleged diagnosis-related negligence resulted from both diagnostic delays and failure to diagnose. They are subdivided into five clinical diagnostic categories: (a) cardiovascular events, (b) neoplasms, (c) infections, (d) gastrointestinal events, and (e) claims involving thrombotic thrombocytopenic purpura (TTP).
	a.	Cardiovascular Events: 48 percent of the diagnosis-related claims involved cardiovascular events (55 percent when atrial fibrillation was included; it was also listed as a medication management–related event). Of these cardiovascular events, 23 percent involved myocardial infarction (MI), 21 percent involved pulmonary embolism, 19 percent involved aortic aneurysm (over half were aortic dissections), 12.5 percent involved atrial fibrillation, and 12.5 percent involved failure to diagnose arteriosclerotic heart disease (ASHD). These are listed in Table 3.
	b.	Neoplasms: 31 percent of the diagnosis-related claims involved neoplasms. Of these claims, 79 percent resulted from a delay in diagnosis and 21 percent from failure to diagnose. The cancers (Ca) involved are listed in Table 4.
	c.	Infections: 9 percent of the diagnosis-related claims involved infections. Half resulted from failure to timely diagnose epidural abscess (#4) resulting in paraplegia and/or incontinence, and half resulted from failure to diagnose osteomyelitis (#4: two were vertebral, one foot, and one sternoclavicular joint). Three of the epidural abscesses were associated with a urinary tract infection and one with amethicillin-resistant Staphylococcus aureus (MRSA) septicemia.
	d.	Gastrointestinal Events: 8 percent of diagnosis-related claims involved gastrointestinal events. These were almost evenly divided between failure to timely diagnose appendicitis resulting in rupture and peritonitis (#3) and acute pancreatitis (#4).
	e.	Thrombotic Thrombocytopenic Purpura: 3.5 percent of repetitive diagnosis-related claims involved TTP. One was in a patient with systemic lupus erythematosus (and misdiagnosed as lupus cerebritis); one followed administration of Lovenox + Ticlid, resulting in seizures and death; and one followed a quinine dose, resulting in a hemolytic uremic syndrome with renal failure necessitating renal transplant.
2.	Improper Medication Management Claims: Improper medication management was alleged in 21 percent of repetitive claims (Table 5). Note that 59 percent (#16) of these medication management events involved anticoagulants and that 81 percent (#13) of anticoagulant claims involved Coumadin. Furthermore, 46 percent of the Coumadin claims resulted from failure to monitor using the international normalized ratio (INR).
3.	Improper Management and/or Treatment Claims (9 percent) Included:
	•	TIA improper management (#3)—resulting in cerebrovascular accident (CVA)
	•	Hypertensive patients with TIA (#3)—resulting in CVA
	•	Hypertension, improper management (#3)—resulting in cerebral hemorrhage
	•	Hyperkalemia, improper management (#2)—resulting in fatal cardiac arrhythmia
	•	Acute MI, improper management (#1) of fatal cardiogenic shock
4.	Patient Monitoring Claims (3 percent) Included:
	•	Jugular vein occlusion (#1)—in a patient receiving heparin through a subclavian vein catheter
	•	Failure to monitor blood pressure post cardiac catheterization (#1)—a defective Angio-Seal at the inguinal catheter site caused fatal retroperitoneal bleeding
	•	Axillary vein thrombosis (#1), while placing a jugular vein catheter resulted in arm amputation
	•	Femoral artery laceration (#1), while placing a Swan-Ganz catheter caused fatal hemorrhage

Discussion
Malpractice claims analysis provides valuable information about medical errors, system failures, and high-risk clinical events that contribute to adverse patient outcomes—and we believe that disclosing this data will enhance patient safety. Analysis also suggests clinical risk management and patient safety topics appropriate for Continuing Medical Education and Maintenance of Certification educational programs. Based on this claims analysis, the following subject areas are candidate topics:

The Doctors Company is committed to examining important risk management and patient safety issues, and we will continue to publish this information to help advance the practice of safe medicine. 

For more information, visit our Knowledge Center at www.thedoctors.com/knowledgecenter.

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