Cardiology Closed Claims Study

The Doctors Company conducted a review of diagnostic cardiology claims that closed between 2014 and 2019. This study was based on claims and lawsuits filed against almost 500 cardiologists insured by The Doctors Company. There were 210 cardiology claims.

Patient Injuries

Cardiology patients suffered a variety of injuries. The 10 most common injuries that prompted claims or suits included:

Patients may suffer more than one harm, so the total is greater than 100 percent.

Injury Severity

Injury severity has not changed significantly in the last 12 years. A comparison of the 2008–2013 study with the 2014–2019 study shows only 1 percent difference in the number of cardiology patients who experienced a high-severity injury, the largest category of injuries.

Cardiology Patient Injury Severity 2014–2019

Cardiology Patient Injury Severity 2008–2013

Indemnity and Expense

Thirty-one percent of cardiology claims resulted in a payment to the patient or their family.


Mean indemnity paid


Mean expense paid


Mean indemnity paid


Mean expense paid

Rate of Claims Per 100 Full-Time Equivalents

The rate of claims for cardiologists has declined most years from 2005 until 2018. The high was 11.4 percent in 2008 and lows were recorded at 6.0 percent in 2014 and 2015.

Overall, the number of claims filed against cardiologists has decreased over the last 14 years. However, it could be argued that the rate of claims in the last five years is starting to increase. Either way, it is important to explore ways of reducing the number of patient injuries.

Regardless of the trendline, claims and suits that have been filed continue to have a high percentage (67 percent) of high-severity injuries. A focus on these cases yield insights that help reduce the frequency and severity of patient injuries.

Site or Type of Facility

Most cardiology claims arose from care provided in the hospital setting (59 percent). Physician offices were the second most common site (34 percent). The other 7 percent were spread between psychiatric hospitals (1 percent), ambulatory surgery centers (1 percent), skilled nursing centers (1 percent), and unknown (4 percent).

Within hospitals, the most common locations for care that resulted in claims were patient’s room (29 percent), cardiac catheterization lab (13 percent), special procedures (6 percent), intensive care units (6 percent), operating rooms (5 percent) and emergency departments (3 percent).

Sex of Patients

The frequency at which males and females are represented in cardiology claims has remained consistent since our last study in 2014.

Cardiology Claims by Sex 2014–2019

Cardiology Claims by Sex 2008–2013

Ages of Cardiology Patients

The peak age range for cardiology patients at the time the alleged injuries occurred was 63 to 71. Other, smaller peaks were seen in the mid-40s and again in the late 70s.

Types of Claims

There were five primary types of cardiology claims:

These case types make up 74 percent of cardiology claims.

Diagnosis-Related Claims

Diagnosis-related claims made up 33 percent of cardiology claims. The 10 most frequent final diagnoses associated with diagnosis-related cardiology claims were aortic aneurysm (15 percent), acute myocardial infarction or cardiac arrest (13 percent), atherosclerosis of native coronary (11 percent), acute and subacute endocarditis (8 percent), pulmonary embolism (4 percent), cerebral artery thrombosis or occlusion (4 percent), malignant neoplasm of bronchus or lung (4 percent), cardiac dysrhythmia (3 percent), congestive heart failure (3 percent), and central nervous system complications (3 percent).

On average, three to four contributing factors are coded on each claim. In this study, the factors that contributed to diagnosis-related claims included inadequate patient assessments (76 percent of diagnosis-related claims), failures in communications among providers (26 percent), patient factors (21 percent), lack of communication between patients/families and providers (17 percent), errors in selection and management of therapy (16 percent), failure or delay in obtaining a consult or referral (16 percent), and insufficient or lack of documentation (14 percent).

The most common factor, inadequate patient assessments, is consistent with the most common case type, diagnosis related (failure, delay, incorrect). Assessments were found to include delays in ordering diagnostic tests that were identified by physician reviewers. Another factor was failure to appreciate and reconcile relevant signs, symptoms, and test results. Misinterpretation of diagnostic studies was another deficiency in these assessments.

Failures in communication occurred among providers. Some were due to failing to review all relevant information in patients’ records. On other occasions important information was lost in transitions of care and/or handoff communication.

Patients’ behaviors were a factor in one out of five cardiology cases. Patients either refused to have tests performed or were not adherent to treatment medication plans. It could not be determined from this study whether patients failed to understand information provided by their cardiologist or decided not follow advice for reasons such as fear or lack of resources to pay for the care.

Factors that contributed to patient harm:

  1. Inadequate patient assessments (76 percent)
    1. Failure or delay ordering diagnostic tests
    2. Failure to appreciate and reconcile relevant signs, symptoms, or test results
    3. Misinterpretation of diagnostic studies
    4. Failure to establish a differential diagnosis
    5. Narrow diagnostic focus with an atypical presentation
  2. Failures in communication among providers (26 percent)
    1. Regarding the patient’s condition
    2. Failure to read medical record
    3. Information lost during transitions of care and/or handoff communication
  3. Patient factors (21 percent)
    1. Patient not adherent to follow-up appointments
    2. Patient not adherent to medication or treatment plan
  4. Lack of communication between patients/families and providers (17 percent)
    1. Regarding follow-up instructions
    2. Regarding patient’s expectations
  5. Errors in selection and management of therapy (16 percent)
    1. Invasive procedures
    2. Medical treatments
    3. Failure to order medications
  6. Failure or delay in obtaining a consult or referral (16 percent)
  7. Insufficient or lack of documentation (14 percent)
    1. Regarding clinical findings
    2. Regarding clinical rationale
    3. Regarding follow-up efforts

Risk Management Strategies to Prevent Diagnostic Errors

  • Take a detailed medical history and conduct a thorough patient assessment—patient complaints are an essential source of information to assist cardiologists in making correct diagnoses.
  • Consider and document differential diagnoses for all new problems or recurring, unresolved signs and symptoms. Timely diagnosis and treatment often depend on how quickly diagnostic studies are performed, interpreted, and acted on.
  • Beware of breakdowns in communication, which have been associated with diagnostic error. Communication occurs during various parts of the diagnostic process, such as the initial patient assessment; tests, results, and processing; follow-up, and coordination. In today’s hurried healthcare environment, it is essential that cardiologists not only provide the information to the patient, but that the patient provides some response to that information that confirms understanding. Consider adopting a quick, structured approach to confirming understanding such as Ask Me 3.
  • Respond quickly to the results of tests that have been ordered. This is key to timely diagnosis. Track studies and follow up on critical test results. If results are delayed, notification should come from the testing department (laboratory or radiology, for example). If test results are not received when expected, follow up to determine the cause of the delay. This step may reduce unnecessary delays in diagnosis and treatment.
  • Be alert for ancillary findings of imaging studies. Lung nodules or other findings indicative of possible malignancy need to be addressed. Be sure to alert primary care providers and patients of these findings to make sure that follow-up diagnostic studies are performed and care is provided.
  • Assess for depression. Studies show as many as 30 percent of post heart attack patients may experience depression

Improper Management of Treatment Claims

Improper management of treatment was the second most frequent case type. The final diagnoses most frequently associated with improper management of treatment included:

Fourteen other diagnoses made up 2 percent or less of cases each.

Improper management of treatment was found to be due to inadequate assessments (40 percent of these cases). Physicians failed to appreciate and reconcile relevant signs, symptoms, and test results when patients had unresolved symptoms. In some cases, it was determined that physicians failed to order or delayed ordering diagnostic tests or misinterpreted the diagnostic studies when they received them.

There were also alleged errors in selection and management of therapy. They included selection of medical treatment, selection of medications, and failure to order medications.

Inadequate communication between patient or family and provider was the third most common factor leading to patient injury. Patients needed more information about treatment options, patient education regarding the risks of medications, and discussion regarding their expectations about the outcomes of care.

Risk Management Strategies to Prevent Improper Management of Treatment

  • Consider all symptoms and test results when making treatment recommendations—and communicate how these symptoms and test results yield various choices available to the patient, so that they can make informed decisions. Document all informed consent discussions.
  • Be accessible and responsive to nurses. Build rapport. When nurses call to report changes in patients’ status, respond to their concerns. Ask nurses if they think that you should evaluate the patient. If they say no, ask, “Are you sure?” This communicates a message of trust in nursing judgment and will encourage future calls when nurses have concerns about the patients in their charge.
  • Treat handoffs and referrals as essential processes in good care. Foster healthy relationships with other clinicians. Provide them with the information that they need to effectively receive handoffs or to provide consultations.
  • Communicate concerns and fears to nurses about specific patients. Prepare them to receive pending test results and provide guidance on how to respond.
  • Review all documentation to ensure that you are aware of all consultation reports, consultant orders, and any changes to the patient’s condition documented by nursing.
  • Encourage cardiac rehabilitation. Over the years, research has shown that patients who participate in cardiac rehab programs have better outcomes compared to those who do not participate.

Improper Medication Management Claims

The third most common case type was improper medication management. These cases arose from selection of medications, nonadherence by patients to medication and other treatment plans, and inadequate education regarding the risks of medications.

In most of these cases, the care and treatment were found to meet the standard of care.

Risk Management Strategies to Prevent Improper Medication Management

  • Provide education on medications prescribed for the patient, including why the medication is needed, its risks, and its side-effects. Allow time for questions from the patient on these medications. Providing written materials on medications is beneficial.
  • Document patient nonadherence or refusal to follow treatment plans. Use quotes from patient and family members. This documentation is essential in situations where cardiologists need to defend the care that was provided.
  • Take time to build rapport with your patient. Increased levels of trust may result in a higher level of patient adherence to physician instructions and treatment plans.
  • Request that patients bring all medication bottles to each clinic visit as part of the medication reconciliation process.

Improper Performance of Treatment or Procedure Claims

One case involved improper placement of a pacemaker, resulting in clavicle pain and the need for repositioning, as well as the use of a guidewire too large during cardiac catheterization, resulting in a perforation in the right coronary artery and ultimately death.

Incorrect or Unnecessary Treatment or Procedure Claims

One case included implanting an internal cardiac defibrillator without documented clinical indications, which resulted in a pneumothorax and extended hospitalization.

Another case included placement of a coronary stent with stenosis without documented clinical indications such as the results of the intravascular ultrasound (IVUS).

The Value of Communication

The number of claims that are filed against cardiologists has decreased over the last 14 years. The rate of claims in the last five years seems to indicate that the frequency has leveled off between six and eight claims per 100 FTEs.

The lower rate of claims is an improvement but raises questions about what is needed to reduce the number of patient injuries and the resulting claims even further. One consideration is the percentage of high-severity injuries and death. They have remained stable over the last 13 years. This may be an encouraging statistic considering the increased ages of patients and the increased complexity of procedures. However, efforts to reduce the number of complications and other injuries are needed.

Only 31 percent of claims filed against cardiologists resulted in a payment to the patient or their families. Although it is often difficult to determine the actual cause of undesirable patient outcomes, this statistic seems to indicate that almost 70 percent of claims and suits were not based on negligent care. This raises the question of how to address patients’ concerns and questions so that they do not feel the need to file these claims and suits.

One possible strategy is to closely monitor patient outcomes and identify those with less than desirable results, because patients who have unresolved questions may surmise that undesirable outcomes were due to substandard care. Even with excellent informed consent discussions, it is unlikely that most patients have high enough medical literacy to be able to understand the mechanism of their results. In almost every case, patients need to talk with their cardiologists to understand the reasons for their outcomes. Taking the time to provide explanations will help to satisfy patients’ concerns and build the trust that is needed for successful physician-patient collaboration—which becomes more important, not less, when the patients’ desired outcomes are not able to be achieved.

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.