In a review of claims closed by The Doctors Company from 2013 through 2018, we identified 220 claims with a final diagnosis of acute cerebral vascular accident (CVA). Our review included case types, factors that contributed to patient harm, patient injuries, patient injury severity, locations where the patient allegedly suffered harm, and comorbidities that affected the outcome of care.
The information obtained from analyzing these claims provides useful statistics and insightful risk reduction strategies that can help physicians improve patient safety. The two case summaries also provide valuable information about the factors that contribute to CVA claims.
Most Common Case Types Related to CVA
The most common types of cases included claims related to diagnosis (failure, delay, wrong) (40 percent), management of treatment plan (25 percent), and medication management (10 percent).
Accurate diagnosis was the most difficult challenge when patients presented with symptoms that may arise from intracranial vascular occlusions or bleeding. Factors related to diagnosis of stroke that contributed to patient injuries included inadequate patient assessments (71 percent), failure or delay in ordering diagnostic tests (28 percent), and lack of communication among providers (27 percent).
Patient assessment issues included failure to appreciate and reconcile relevant signs, symptoms, and test results and failure or delay in ordering diagnostic tests. Other factors related to patient assessments were misinterpretation of diagnostic studies and overreliance on negative findings for patients with ongoing symptoms.
One additional factor in diagnosis-related claims was failure or delay in obtaining a consult or referral. Although some symptoms warranted an assessment by a neurologist, the patient was not referred because the diagnosing physician did not feel that the symptoms justified additional evaluation.
Communication among clinicians regarding patients’ conditions was a factor in 27 percent of diagnosis-related claims. In some cases, important information was not given to the clinicians providing care to the patient. In other cases, information was lost during transitions of patient care.
Patient safety/risk management issue: patient assessment issues with failure to establish a differential diagnosis.
A 57-year-old female presented to the hospital for reversal of a jejunal bypass and conversion to gastric bypass with a diagnosis of morbid obesity. The patient had undergone the jejunal bypass approximately 15 years earlier and suffered from daily diarrhea. The insured general surgeon had performed fewer than six other operations of this type.
The patient was taken to the operating room and had no complications noted during the surgery. Postoperatively, she was transferred to the postanesthesia care unit (PACU) and did well. She was then transferred to the surgical floor.
On the second postoperative day, the family told the nurses that the patient was confused and nonresponsive. The nurses attributed the patient’s condition to the pain medication and did not call the doctor. On the third postoperative day, the patient had a high temperature and was hypotensive, nonresponsive, and draining foul-smelling brown fluid from the wound site.
The general surgeon examined the patient, suspected a leak, and transferred her to the ICU, but the patient was not taken to the operating room until approximately 12 hours later. The medical record contained no explanation for the delay.
Once in the OR, the general surgeon repaired a small leak at the anastomosis. Copious foul-smelling fluid in the abdomen was irrigated with antibiotic solution and drains were placed. The patient was then transferred to the ICU and placed on a ventilator. The nurses noted that the patient was not moving her left side. A CT of the brain revealed a cerebral infarct.
The patient was transferred to a larger hospital for a neurosurgery consult but expired two days later. The cause of death was determined to be multiple brain infarcts. The plaintiff’s experts alleged that the brain infarcts were related to sepsis from the leak and that the leak should have been recognized and repaired sooner.
Patient safety/risk management issue: failure to diagnose and delayed treatment of CVA.
A 76-year-old male presented to the emergency department of the insured hospital. He stated that he had fallen and complained of pain in the left wrist. A small abrasion was noted at the left lateral eyebrow. The patient said he had lost consciousness for a few seconds.
He was diagnosed with new onset of atrial fibrillation with syncope, comminuted Colles’ fracture, and facial abrasion. The patient was admitted with an internal medicine doctor as the attending. A cardiology consult for atrial fibrillation was done. The cardiologist recommended starting Lovenox and Coumadin. The patient was recovering well. At 9:00 PM, the nurse noted the patient was staring but responding appropriately. At 9:45 PM, the nurse noted the phone rang and the patient attempted to answer it using the urinal. At 10:35 PM, the nurse noted the patient was not oriented to name, place, or time.
The nurse notified the attending physician, who ordered “give Haldol 2 mg IM every four hours for agitation as necessary.” At 11:37 PM, the patient’s family notified the nurse that the patient was acting strangely. The nurse noted that his pupils were equal and reactive to light. At 12:10 AM, the patient was noted to be sleeping. The patient was found on his knees beside the bed at 1:00 AM. The patient complained of a slight headache, and a question was raised about whether he had hit his head. The nurse called the doctor, who ordered “non-stat CT of head in the morning, get blood urea nitrogen and creatine, and may restrain the patient.” During the rest of the night, the patient was noted to be sleeping.
At 8:00 AM, the shift changed, and a new nurse noted the patient was unresponsive, with pupils that were unequal and sluggish. The nurse did not call the doctor because she thought the doctor would be in shortly for rounds. The doctor arrived approximately 45 minutes later.
The doctor ordered a stat CT of the brain, which was read as left cerebral hemorrhage. The patient was made do-not-resuscitate status and expired that afternoon.
The plaintiff alleged that delayed diagnosis and delayed treatment of the CVA led to the patient’s death. The plaintiff’s experts felt that the first nurse should have gone up the chain of command to get help for the patient since he was clearly having decreased mentation. Experts also felt that when the patient was found unresponsive, the second nurse should have called the doctor immediately rather than waiting for the doctor to make rounds on the patient.
Lessons Learned from These Case Studies
Both case studies examined involved the diagnosis and treatment of CVA in which care was found to be lacking.
Because CVA is relatively common, the physician should include it in the differential diagnosis for any patient who complains of the typical signs and symptoms: headache, confusion, numbness or paralysis of one side of the body, blurred vision, or difficulty with speech.
It is important that staff also recognize the common symptoms of CVA, and it is imperative that nurses relay changes in a patient’s condition to the physician. Communication and teamwork can result in a faster diagnosis, earlier treatment, and a better prognosis for the patient.
Improper Management of Treatment Plan
Improper management of treatment included selection of treatment and failure to order medications (such as t-PA and other anticoagulants). In some cases, patients presented with symptoms of headache, weakness, or visual symptoms. Other cases involved patients who were scheduled for cardiac procedures and experienced thrombosis when not anticoagulated.
When treatment was delayed, physicians were sometimes criticized for failing to recognize relevant signs and symptoms, or radiologists were found to have failed to correctly interpret imaging studies.
Improper Medication Management
The most common criticism in improper medication management allegations was failure to order medications (such as anticoagulants). In some cases, the most appropriate medication was not used. Other allegations included inadequate documentation of medication use and physician failure to educate patients on the risks of medications.
Services Responsible for Patient Care
We found the following in a review of the top clinical services responsible for care when the patient suffered harm from a CVA:
- Emergency medicine (16%)
- Neurology (12%)
- Cardiology (9%)
- Hospitalist (9%)
- Internal medicine (9%)
- Family medicine (7%)
- Radiology (6%)
Patients were admitted to the hospital in about half of the cases involving allegations related to stroke. In 25 percent of these cases, the patient was evaluated and treated in an outpatient setting (including the physician’s office). In 24 percent of these cases, the patient presented to an emergency department to have the complaint evaluated.
- Inpatient (51%)
- Outpatient (25%)
- Emergency department (24%)
The nine levels of injury severity as defined by the National Association of Insurance Commissioners on its Injury Severity Scale are listed below with the percentages of patients in our study diagnosed with stroke. Note that none of the cases were in the low-severity range. Twenty-one percent were in the medium-severity category, and almost 80 percent were in the high-severity category.
- Emotional only (0%)
- Temporary insignificant (0%)
- Temporary minor (1%)
- Temporary major (2%)
- Permanent minor (18%)
- Permanent significant (26%)
- Permanent major (18%)
- Permanent grave (3%)
- Death (32%)
Where Injuries Occurred
We found that patients suffered the effects of CVAs prior to presenting for care, after presenting to physicians’ offices and emergency departments with complaints, and during hospitalization. Here are where the injuries occurred:
- Patient’s room (35%)
- Emergency department (23%)
- Physician office (19%)
- Intensive care unit (7%)
- Ambulatory/day surgery (4%)
- Radiology/imaging (4%)
- Special procedure (3%)
- Hospital operating room (2%)
- Cardiac catheterization laboratory (1%)
- Extended care facility (1%)
- Off-site/other facility (<1%)
Top Comorbidities Contributing to Claims
Although patients presented with comorbidities, only those comorbidities regarded by physician reviewers as having contributed to the event and/or injury or illness were included in the study.
- Hypertension (30%)
- Cardiovascular disease (18%)
- Diabetes (12%)
- Obesity (10%)
- Smoking (8%)
- Cerebrovascular disease (4%)
Factors Contributing to Patient Injury
We focused on the top five factors that contributed to harm in cases in which patients were diagnosed with CVA. We included subcategories to provide additional clarity.
Note that patients may experience more than one factor, so the totals are greater than 100 percent.
- Patient assessment issues (44%)
- Failure to appreciate and reconcile relevant signs, symptoms, and test results (19%)
- Failure or delay in ordering diagnostic tests (15%)
- Failure to establish a differential diagnosis (10%)
- Misinterpretation of diagnostic studies (x-rays and other radiographic studies) (7%)
- Inadequate history and physical (6%)
- Communication among providers (27%)
- Regarding patient’s condition (23%)
- Information lost during transitions in care (3%)
- Failure to read medical record (3%)
- Selection and management of therapy (25%)
- Failure to order medication (10%)
- Selection of medical treatment (6%)
- Selection of invasive procedure (5%)
- Insufficient or lack of documentation (20%)
- Clinical findings (6%)
- Clinical rationale (5%)
- Review of care (4%)
- Failure or delay in obtaining a consult or referral (18%)
Risk Mitigation Strategies
Consider the following patient safety strategies:
- Educate staff on recognizing and responding to the signs and symptoms of CVA. Triage protocol training is essential to facilitate physician evaluation in a timely manner.
- Conduct thorough assessments including a comprehensive history and physical exam and consider all differential diagnoses. Provide close supervision with advanced practice providers and doctors in training. Offer education programs to all patient care staff to enhance their assessment, communication, and decision-making skills.
- Promote team building activities and a culture of respect among all staff and physicians.
Implement the TeamSTEPPS® program from the Agency for Healthcare Research and Quality. Use TeamSTEPPS skills to encourage mutual support, promote conflict resolution strategies, and enhance team communication with structured handoffs that minimize errors and prevent delays in treatment.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.