The Doctor’s Advocate | Third Quarter 2016
An Ounce of Prevention
Internal Medicine Closed Claims: What Can We Learn?
We have just released the Internal Medicine Closed Claims Study, the latest in our nationally recognized series analyzing claims data from our 78,000 members. This study, which evaluates 1,180 internal medicine claims that closed from 2007–2014, provides insights into the most likely risks encountered by internal medicine physicians. Here is a brief overview.
—Robin Diamond, JD, RN
An examination of the most common patient allegations in internal medicine claims revealed that the majority were related to diagnosis (failure, delay, wrong) (39 percent), medical treatment (32 percent), and medication (19 percent). These three allegation categories accounted for 90 percent of all allegations in internal medicine claims.
Diagnosis-related allegations were made when a missed, delayed, or incorrect diagnosis resulted in patient injury. Diagnosis-related allegations in internal medicine claims are seen most often with myocardial infarction (MI), lung cancer, colorectal cancer, prostate cancer, acute cerebrovascular accident, pulmonary embolism, and breast cancer.
CASE EXAMPLE: A 60-year-old female came to her internist’s office complaining of fatigue, abdominal pain, and rectal bleeding. She was referred to a gynecologist, who performed an ultrasound that revealed a likely uterine fibroid. An endometrial biopsy was benign. No other workup was done. She continued to complain of fatigue and of abdominal and rectal pain, but the internist ordered no further diagnostic studies.
Several months later, the internist ordered a CT of the abdomen. It showed a mass displacing the uterus. The patient was diagnosed with stage IV rectal cancer and died soon thereafter.
This physician relied too heavily on the negative ultrasound and biopsy findings in the face of continued patient complaints. The physician also failed to follow up on the patient’s rectal bleeding. She should have been referred earlier for imaging studies.
CASE EXAMPLE: A 66-year-old male with a history of smoking had a screening chest x-ray that showed a 2 cm density. A follow-up CT with contrast was recommended. The patient saw his internist, who noted the findings and ordered a repeat chest x-ray to be done in the next three months. The repeat chest x-ray was never performed. The patient was subsequently diagnosed with lung cancer and liver metastases and died shortly thereafter.
It was not clear whether the physician communicated to the patient the need for follow-up studies. The office did not make an appointment for the patient to have the follow-up chest x-ray or the CT with contrast. Because the office did not track orders for follow-up studies, there was no mechanism for determining whether the patient had undergone the necessary tests.
Medical Treatment Allegations
Medical treatment allegations, the second most common internal medicine allegation at 32 percent, involved failures in the selection or implementation of a treatment. Contributing factors included:
- Failure or delay in obtaining a consult or referral.
- Failure or delay in ordering diagnostic tests.
- Failure to consider available clinical information.
- Inadequate communication among healthcare professionals about the patient’s condition.
CASE EXAMPLE: A 42-year-old female nonsmoker presented to her internist for a cough that was nonresponsive to antibiotics and albuterol treatments. A chest x-ray was ordered and showed a 4.2 cm mass. The radiologist stated that a neoplasm could not be ruled out, and a CT scan was recommended. The internist sent a letter to the patient advising her to make an appointment for the CT scan.
The patient did not return to this physician, and the physician made no subsequent attempts to communicate with her. She saw another internist, but her medical records and chest x-ray report were never sent to the new physician. Eighteen months later, she was diagnosed with stage III lung cancer.
Although patients have responsibility for managing their own healthcare, physicians are expected to make reasonable attempts to communicate when there is a suspected health concern.
In this case, the physician sent a letter advising further studies. It is not clear whether the physician communicated the urgency of performing the studies or if he alerted the patient that failing to investigate the lung mass was potentially life threatening. More than one attempt to contact the patient should have been made. Without tracking mechanisms, opportunities to provide medical treatment are easily lost and forgotten.
Medication management was an allegation in 19 percent of the claims. Medication-related allegations included failure to appropriately monitor anticoagulants, failure to address medication side effects, and failure to identify drug interactions.
CASE EXAMPLE: A 24-year-old female saw an internal medicine physician for back and neck pain resulting from an accident. Examination revealed spasms in the neck and lumbar areas. The internist ordered Xanax, Norco, and Soma in appropriate dosages. The patient was advised about the medications’ addictive properties. The patient returned one month later with ongoing pain and was provided additional pain medications. Two weeks later, she went to the ER with a drug overdose. This incident was not reported to her internist.
A few days later, the patient’s father picked up another prescription for the patient. She returned for two more office visits with the same symptoms and exam findings. The internist again warned her of the addictive properties of opioids and encouraged her to enter a rehab program. A few weeks after the last office visit, the patient died of a drug overdose. It was later discovered that she had also been seeing a pain management physician and had also received pain medications from that provider.
The internal medicine physician failed to monitor the patient’s opioid prescriptions through the state’s drug monitoring program. He should have referred her to a pain medicine specialist and to a rehab program for evaluation and treatment of her addiction.
This study identified 84 different types of patient injuries, reflecting the wide array of conditions treated by internal medicine specialists. However, the most common result of injury was death (44 percent of claims). Of those cases, the most common allegation was failure or delay in diagnosis (41 percent).
The second most common injury was infection (16 percent) that remained undiagnosed until the patient suffered harm. The most frequent types of infections included sepsis, pneumonia, and spinal epidural abscess, but we also saw claims that involved endocarditis, peritonitis from intestinal perforation, and postoperative infections.
Malignancy (13 percent) was the third most common patient injury, followed closely by adverse reactions to medications (12 percent). Malignancy injuries resulted from conditions that were not diagnosed or treatment that was not managed appropriately. Adverse reactions to medications were caused when the patient received insufficient information regarding the risks of medications, the medication was inappropriate for the patient’s condition, or therapeutic drug level monitoring was insufficient.
Factors Contributing to Patient Injury
Physician experts provided insights on the causes of patient harm. While multiple factors, such as clinical judgment, technical skill, patient behaviors, communication, clinical systems, or documentation, may contribute to patient injury, the major contributing factor involved patient assessment issues (33 percent). Examples included failure to establish a differential diagnosis, failure to order diagnostic tests, inadequate history and physical examinations, and failure to address abnormal findings.
Risk Mitigation Strategies
The following strategies can help internal medicine physicians avoid risks revealed by the claims analysis:
- Follow up on patient complaints, especially when patients return to the office with the same or similar complaints. Patient complaints are the first opportunity to gather information and form the basis of an accurate history and assessment, both crucial for diagnosis and treatment decisions.
- Track diagnostic test results to ensure that they have been received, reviewed, and communicated to the patient and that any necessary action was taken. Staff members should have clear policies and procedures to follow for each step in the process.
- Track and manage the referral process, even if the patient makes his or her own appointment. Patients and referral physicians should be clear about the urgency of the referral, and the recommended timing should be documented. Follow up if you do not receive the consultative report as expected by your tracking system.
- Educate patients on the risks of medications and the symptoms that require follow-up with the provider. Ask patients about their intentions to follow instructions or purchase medications, and provide information on community resources if an inability to pay will cause noncompliance.
- Engage the patient as part of the team to keep the physician informed on progress and to improve follow-through with the treatment plan. Have the patient repeat back the care instructions, medication regimen, and follow-up plan to verify understanding.
- Be responsive to patients with atypical chest pain, including patients in their 40s. In this study, 22 percent of patients with MI or cardiac arrest (the most common diagnosis-related injuries) were in their 40s and presented with atypical chest pain.
- Be alert to calls and concerns from postoperative patients. Internists are often called upon to provide postoperative care at a time when patients are unable to determine whether symptoms are a normal part of recovery or are complications that need medical assistance.
Read the full study, including expanded case examples and risk mitigation strategies, at www.thedoctors.com/internalmedicinestudy.