The Doctor’s Advocate | First Quarter 2016
Analysis of Closed Hospitalist Claims
by Darrell Ranum, JD, CPHRM, Vice President, Department of Patient Safety and Risk Management, David B. Troxel, MD, Medical Director, Board of Governors, and Robin Diamond, JD, RN, Senior Vice President, Department of Patient Safety and Risk Management
We analyze the claims of our 78,000 members and translate the findings into patient safety initiatives that protect our members and their patients. Analyzing the collective experience of so many physicians provides an extensive database of specialty-specific information, which we share with members through The Doctor’s Advocate and our website.
We also present specialty-specific claims analyses to our specialty advisory boards. The physicians who participate in our Anesthesia, Hospitalist, OB, and Orthopedic Advisory Boards are leaders who are recognized at a national or regional level. We meet to discuss new procedures, surgical techniques, treatments, and technologies, as well as trends and concerns that the individual specialties face in this rapidly changing healthcare delivery system.
—David B. Troxel, MD
We analyzed 464 claims* against hospitalists that closed from 2007–2014. The study, based on the claims experience of more than 2,100 hospitalists insured by The Doctors Company, includes all claims and lawsuits (cases) in which a hospitalist was named as a defendant.
Regardless of the outcome, all cases that closed from 2007–2014 were included in this analysis—an approach that helps us better understand what motivates patients to pursue claims and to gain a broader overview of the system failures and processes that resulted in patient harm.
Most Common Patient Allegations
Seventy-eight percent of all claims against hospitalists included the three most common allegations, as demonstrated in Figure 1 and in the following discussion.
36% Diagnosis related (failure, delay, wrong). This allegation was made when the patient’s condition was incorrectly diagnosed or the diagnosis was delayed to the detriment of the patient’s health. The conditions that most commonly involved incorrect or delayed diagnosis included intestinal disorders, such as obstruction, perforation, and vascular insufficiency (16 percent), cerebral artery occlusion and acute cerebral vascular accident (CVA) (7 percent), acute myocardial infarction (MI) and cardiac arrest (6 percent), sepsis and toxic shock syndrome (5 percent), pulmonary embolism (PE) (5 percent), spinal epidural abscess (4 percent), lung cancer (4 percent), viral and bacterial pneumonia (3 percent), subacute and acute endocarditis (3 percent), and aortic dissection or aneurysm (3 percent). Physician reviewers noted that 35 percent of these cases resulted from an inadequate initial assessment, consequently decreasing the chance that the hospitalist would arrive at the correct diagnosis.
Case Example: A 50-year-old female presented to the ER with a three-day history of fever, chills, and pain in her neck and back. Assessment revealed weakness in her right arm and dysuria. The WBC was 21,000 with a left shift. The patient reported a history of IV drug abuse.
She was admitted with a diagnosis of pyelonephritis. She was unable to move her neck, and her grip in both hands was weak. The hospitalist prescribed an antibiotic and pain medication. An MRI was considered but not ordered because C-spine x-rays showed no abnormalities.
On the third day of her hospitalization, the patient complained of extreme upper extremity pain and decreased bilateral extremity movement. Following a shift change, a different hospitalist was called to see the patient and suspected a cervical epidural abscess. He ordered an urgent MRI that confirmed this diagnosis. The patient was immediately taken to surgery but became quadriplegic due to spinal cord compression. The first hospitalist was found liable for failing to order an MRI, which resulted in the delay in diagnosis.
31% Improper management of treatment. This allegation is related to decisions about the patient’s care after diagnosis. Examples include inadequate assessments of foot and decubitus ulcers resulting in sepsis and inadequate management of diabetic patients resulting in ketoacidosis, pyelonephritis, DIC, and loss of lower extremities.
In some of these cases, the patient was not assessed or managed for a period of time that experts considered excessive.
Case Example: A postpartum patient was readmitted with severe back pain and placed on antibiotics. Low serum potassium was noted, but there was no further workup or testing. Two days later, the patient collapsed and died from cardiac arrest due to low potassium.
11% Medication-related error. This allegation was raised in a number of situations: sepsis or loss of limb from lack of antibiotics, respiratory failure from excessive doses of narcotics, venous thrombosis in patients with risk factors for thrombosis that were not addressed, bleeding from various sites resulting from failure to discontinue anticoagulants prior to surgery, and toxicity resulting from a failure to monitor medications (such as gentamycin and vancomycin). In other cases, multiple system failures led to an injury or death.
CASE EXAMPLE:A female diabetic on an insulin pump was removed from the pump and received a long-acting and sliding-scale insulin. The electronic health record defaulted to insulin twice daily with meals. The gastroenterologist then changed the patient’s diet to clear liquids. Blood glucose levels were not checked by the hospitalist. Early the next morning, she was found unresponsive with a blood sugar <5 mg/dL. She expired from anoxic brain injury.
5% Improper performance or delay in treatment or procedure. Examples of improper performance allegations include placement of central IV lines resulting in damage to other vessels and attempts to intubate patients resulting in esophageal intubation or causing tracheal lacerations/perforations.
Patients also alleged delays in treatments or procedures, including delayed transfusion for gastrointestinal bleeding resulting in hypovolemia and chest tube placement for pneumothorax that was delayed until after the patient suffered respiratory arrest.
3% Failure to treat. An example is when a patient's cardiac symptoms are not addressed prior to transfer or discharge, resulting in MI or cardiac arrest. Other examples include failure to treat urinary tract infections leading to sepsis, failure to treat diabetic ketoacidosis resulting in dehydration and renal failure, and lack of treatment for cardiac tamponade leading to cardiac arrest.
3% Failure to monitor physiologic status. This allegation was made when patients who exhibited cardiac symptoms were not monitored prior to suffering cardiac arrest. Other examples include brain damage resulting from failure to monitor patients who experience hypoglycemia following changes to their insulin orders and respiratory arrest in patients diagnosed with obstructive sleep apnea who were prescribed narcotic pain medications.
Factors Contributing To Patient Injury
Our physician reviewers identified factors that contributed to patient injury (see Figure 2). Here are their findings on the top six factors, along with some clinically specific points and examples.
35% Patient assessment issues. Inadequate assessments included the following:
- Failure to establish a differential diagnosis.
- Failure or delay in ordering diagnostic tests.
- Failure to consider available clinical information (lab values, diagnostic tests, symptoms, nursing observations).
Case Example: A 20-year-old female presented to the ER with fever, chills, and pain radiating to her back from her right side. She was admitted, and pulmonary and infectious disease consults were ordered. D-dimer levels were elevated. Her chest x-ray showed a right lower lobe infiltrate. The patient was diagnosed with pneumonia and started on antibiotics by the hospitalist.
Subsequently, she complained of shortness of breath and periods of confusion. Her O2 saturation levels ranged from 86 to 89 percent. She later collapsed and died from a PE. Expert reviewers concluded that the elevated D-dimer levels indicated possible venous thrombosis and risk for PE. Failure to order appropriate diagnostic tests and to consider available clinical information were identified as factors contributing to the patient’s death.
23% Communication among providers. This factor contributed to patient harm when important information was not communicated to other healthcare practitioners. In some cases, nurses identified patients who were at risk for deep venous thrombosis or PE or who exhibited changes in neurological status, but they failed to notify a physician. Other cases involved physicians who failed to see or find important clinical information documented in the medical record and, therefore, were unaware of changes in the patient’s condition, medications, diet, and therapies. These types of oversights resulted in lack of coordination of care and, in some situations, caused harm.
Case Example: A 49-year-old male was admitted with chest pain, headache, back pain, and numbness and tingling in his lower extremities. Blood pressures were 154/53 mmHg in the right arm and 117/56 in the left arm. The nurse failed to document these abnormal blood pressure findings in the medical record or to call them to the attention of the admitting hospitalist. The patient was discharged but later found unresponsive at home and died. An autopsy revealed a dissecting aneurysm of the ascending aorta. Lack of communication between nursing and the hospitalist was identified as a critical factor in the patient’s death.
16% Selection and management of therapy. Physician reviewers identified problems with selection and management of treatment and medications. This included cases of mismanaged pneumonia, asthma, infections, sepsis, cardiac arrhythmias, MI, and traumatic injuries. It also applied to improper selection and management of medications, including failing to order any medication, failing to order the most appropriate medication, or ordering the wrong medication.
12% Communication between patient or family and provider. The fourth most common factor was found in cases in which physicians had poor rapport with patients or when language barriers and inadequate medication instructions resulted in harm to the patient. This illustrates the challenges of building rapport with patients and their families over a short time period. Problems also arose when patients expected to see their family physician in the hospital and were surprised to learn that a hospitalist had taken charge of their hospital care.
Communication challenges also included educating patients about their conditions and treatment plans. In 12 percent of cases, failure to comply with treatment plans that included medication instructions contributed to the unwanted outcome. In cases in which a patient was harmed by a medication, reviewers often identified deficiencies in patient education regarding the risks of the medication. In some situations, patients had not been told to contact their physician if they experienced side effects that required intervention.
12% Failure to obtain a consult or referral. There were two types of cases in this category: Either the hospitalist failed to recognize that the patient’s condition warranted the assistance of other specialists, or the hospitalist believed that he or she could manage the patient without assistance.
12% Patient factors. Patient behaviors also affected the outcome of care, highlighting the important role that patients play in their own care and recovery. Examples include patients who were noncompliant with treatment plans, follow-up appointments, and medication plans. A high percentage of claims in this category involved patients who were noncompliant with testing regimens required to monitor anticoagulants and blood glucose levels.
Patient Injury Severity
Claims arising from hospitalist care are more likely to have a higher injury severity than other physician specialties (see Figures 3 and 4). Hospitalists manage high-acuity patients, have limited access to patients’ past medical histories, and often receive patients with serious conditions. These situations require thorough assessments, comprehensive testing, quick diagnoses, timely referrals, and rapid initiation of treatment.
- Hospitalists are on the frontline of patient care and often coordinate the care provided by other specialists on a team. Communication and coordination are essential parts of the hospitalist’s role.
- Common themes in hospitalist cases include the timeliness of diagnoses and the selection of treatment modalities. Often, these decisions depend on the speed that diagnostic studies are ordered and performed. Another factor is how quickly other specialists become involved in a patient’s assessment and treatment. Several of these steps depend on how quickly the hospitalist reviews reports and seeks the assistance of other specialists.
- Patient complaints are the first source of information to assist the hospitalist in arriving at a correct diagnosis. It is essential to take a detailed medical history and conduct a thorough patient assessment.
- Claims arising from hospitalist care are more likely to have a high-severity injury than other physician specialties (see Figures 3 and 4). This fact underscores the importance of vigilance and effective communications and coordination of care with nurses and other physician specialists.
- Some diagnoses have similar presenting patterns. Symptoms of pneumonia with respiratory distress are similar to symptoms of pulmonary embolus. Pulmonary emboli may cause decreased oxygen saturation with confusion and loss of consciousness that can be similar to stroke and hypoglycemia. Any change in mental or other neurological status warrants immediate assessment and evaluation.
- There are a variety of causes of patient harm. In some cases, physicians failed to follow protocols. In other cases, the patient’s presentation was not typical and did not point to a specific diagnosis. The largest number of cases revealed weaknesses in the systems and processes used by members of the healthcare team. Important clinical information can be difficult to locate in electronic health records or be obscured by lengthy progress notes resulting from copy and paste over-documentation. Communications between nurses and hospitalists can fail. Handoffs between hospitalists may not convey critical information, and efforts to reach physicians in other specialties are sometimes unsuccessful.
Read the full study, including expanded case examples and risk mitigation strategies, at www.thedoctors.com/hospitaliststudy.