The Doctor’s Advocate | Third Quarter 2014
Director's Forum

Note: The article that appears below is an updated version of the article published in print.

Diagnostic Error in Medical Practice by Specialty

Dr. Troxel

by David B. Troxel, MD, Medical Director, Board of Governors

Problems related to diagnostic error are the most common allegation in medical malpractice claims, according to industry sources such as the PIAA’s Data Sharing Project.

As the nation’s largest physician-owned medical malpractice insurer, our extensive claims database contains medical records and expert medical opinions that give The Doctors Company an unparalleled understanding of diagnosis-related adverse events. These diagnosis-related events are coded to indicate whether they result from misdiagnosis, delayed diagnosis, or failure to diagnose, among other things.

We reviewed 7,438 claims closed by The Doctors Company from 2007–2013. The claims involved 10 medical specialties. Twenty-five percent of these claims (1,877 claims) were diagnosis related. Our analysis then focused on the variance between these medical specialties in the incidence of alleged diagnosis-related error and the specific diagnoses involved.

Overall, 34 percent of nonsurgical specialty claims were diagnosis related (the number one allegation in these claims). For surgical specialties, 14 percent were diagnosis related (the third most common allegation in these claims).

For each of the following 10 medical specialties, I’ve stated the total number of claims that closed from 2007–2013 and listed the percentage (and total number) of those claims that were diagnosis related. The top five diagnoses involved in each specialty’s alleged diagnosis-related errors are listed in order of frequency.

Pediatrics Claims (144)
61% Diagnosis-Related (88)

Diagnoses involved:

8.0%
4.5%
4.5%
4.5%
2.3%

Meningitis
Pneumonia
Malignant tumor
Benign tumor
Appendicitis

Emergency Medicine Claims (414)
58% Diagnosis-Related (242)

Diagnoses involved:

13.4%
13.4%
5.4%
4.5%
2.5%

Fracture
Acute CVA
Acute MI
Meningitis
Appendicitis/Spinal epidural abscess (each 2.5%)

Internal Medicine Claims (986)
40% Diagnosis-Related (374)

Diagnoses involved:

6.4%
5.6%
5.3%
3.7%
3.7%

Lung CA
Acute MI
Colorectal CA
Pulmonary embolism
Acute CVA

Family Medicine Claims (1,134)
37% Diagnosis-Related (417)

Diagnoses involved:

4.3%
4.3%
4.1%
3.6%
3.4%

Lung CA
Acute MI
Breast CA
Colorectal CA
Prostate CA

Hospital Medicine Claims (350)
34% Diagnosis-Related (118)

Diagnoses involved:

8.5%
5.1%
4.2%
4.2%
3.4%

Acute CVA
Acute MI
Pulmonary embolism
Spinal epidural abscess
Lung CA

Cardiology Claims (447)
26% Diagnosis-Related (114)

Diagnoses involved:

10.5%
6.1%
6.1%
5.3%
5.3%

Acute MI
Punc/Lac, during procedure
Pulmonary embolism
Aortic dissection
Lung CA

General Surgery Claims (885)
16% Diagnosis-Related (143)

Diagnoses involved:

15.4%
9.8%
8.4%
6.3%
4.2%

Punc/Lac, during procedure
Breast CA
Post-op infection
Colorectal CA
Appendicitis

Gynecology Claims (674)
15% Diagnosis-Related (98)

Diagnoses involved:

21.4%
12.2%
9.2%
7.1%
5.1%

Breast CA
Punc/Lac, during procedure
Uterine CA
Cervical CA
Ectopic pregnancy

Orthopedic Claims (1,647)
13% Diagnosis-Related (215)

Diagnoses involved:

11.2%
5.6%
4.2%
3.3%
2.3%

Post-op infection
Bone and soft tissue CA
Compartment syndrome
Fracture malunion
Pulmonary embolism

Obstetrics Claims (757)
9% Diagnosis-Related (68)

Diagnoses involved:

17.6%
7.4%
4.4%
4.4%
2.9%

Ectopic pregnancy
PP hemorrhage
Punc/Lac, during procedure
Appendicitis
Pulmonary embolism

Discussion

The top five diagnoses for each medical specialty’s diagnosis-related claims involve commonly encountered conditions with differential diagnoses that are well-known to most physicians. Furthermore, 52 percent of these diagnoses (12 of 23) are found repeatedly in different specialties; e.g., acute MI appears in emergency medicine, internal medicine, family medicine, hospital medicine, and cardiology. This suggests that knowledge deficiency is not the primary cause of diagnostic error and that other factors play an important role.

These factors may include first-impression or intuition-based diagnoses, narrowly focused diagnoses influenced by a known chronic illness, failure to create a differential diagnosis, impaired synthesis of diagnostic data from various sources (such as medical history, physical examination, diagnostic tests, or consultations), failure to order appropriate diagnostic tests, context errors, failure to follow diagnostic protocols, system-related errors (such as poor communication or electronic health record design flaws), and human-factor errors (such as impaired judgment, fatigue, or distractions).

In an effort to better understand the causes of diagnosis-related error, the Institute of Medicine has appointed a Committee on Diagnostic Error in Health Care. The committee will examine a range of topics, such as the epidemiology of diagnostic error, the burden of harm and economic costs associated with diagnostic error, and current efforts to address the problem.

The committee will propose solutions that may include definitions and boundaries, educational approaches, behavioral/cognitive processes and cultural change, teamwork and systems engineering, measures and measurement approaches, research, approaches to medical liability, and health information technology.

To achieve the desired goals, the committee will devise conclusions and recommendations that will propose action items for key stakeholders—such as healthcare providers, patients and their advocates, healthcare organizations, federal and state policymakers, credentialing organizations, educators, researchers, and the diagnostic testing and health information technology industry.

In conjunction with other foundations and organizations, The Doctors Company Foundation is supporting this project.

As the study progresses over its two-year timeline, The Doctors Company Foundation will keep you informed of the committee’s findings and conclusions.


The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.

The Doctor’s Advocate

Third Quarter 2014

Director's Forum
Diagnostic Error in Medical Practice by Specialty

An Ounce of Prevention
A Team Approach to Reducing Risk

Politically Speaking
Latest News on Challenges to Caps on Noneconomic Damages

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Young Physicians Patient Safety Awards Announced

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