Hospitalist Closed Claims Study

The Doctors Company conducted a review of hospital medicine claims that closed between 2015 and 2018. This study was based on claims and lawsuits filed against almost 1,900 hospitalists insured by The Doctors Company. There were 238 hospitalist claims.

Patient Injuries

Hospitalists’ 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

High-severity injuries occur in a higher percentage of hospitalists’ claims than many other specialties. Seventy-two percent of hospitalists’ patients who filed claims experienced a high-severity injury. This has remained consistent since 2007.

Hospitalist Patient Injury Severity (2015-2018)

Hospitalist Patient Injury Severity (2007-2014)

In contrast, high-severity patient injuries in internal medicine made up 59 percent of their claims. More internal medicine injuries were medium severity (32 percent) compared with 20 percent medium severity for hospitalists’ patients.

Internal Medicine Patient Injury Severity (2015-2018)

Indemnity and Expense

Thirty-two percent of hospital medicine claims resulted in a payment to the patient or their family.


Mean indemnity paid in
hospital medicine claims


Mean expense paid in
hospital medicine claims

Similarly, general internal medicine physicians’ claims resulted in payments in 32 percent of those claims.


Mean indemnity paid in
internal medicine claims


Mean expense paid in
internal medicine claims


Median indemnity paid for
hospital medicine claims


Median expense paid for
hospital medicine claims


Median indemnity paid for
internal medicine claims


Median expense paid for
internal medicine claims

Rate of Claims per 100 Full-Time Equivalents

The rate of claims for hospitalists has declined almost every year from 2006 (21 percent) until 2017 (9 percent). The rate of claims jumped in 2018 to 13 percent.

Internal medicine claims have declined following a similar pattern, but the rate for internal medicine peaked in 2008 at 11 percent and declined to 7 percent in 2017 and 2018.

NR-012_ClaimRates-_Hosp-IntMed_040620_v1 (1).png

Types of Claims

There were three primary types of hospital medicine claims.

These case types make up 90 percent of hospitalist claims.

Diagnosis-Related Claims

In diagnosis-related claims, the most common diagnoses were:

The factors that contributed to patient injury in diagnosis-related claims for pulmonary embolism included failure to order diagnostic tests; failure to establish a differential diagnosis; failure to appreciate and reconcile relevant signs, symptoms, and test results; insufficient documentation of clinical rationale; and premature discharge.

Improper Management of Treatment Claims

The second-most common driver of claims was improper management of treatment (28 percent). In these management cases, physician reviewers found deficiencies with:

There were 19 other deficiencies found, which each were represented in 17 percent or fewer claims.

The most common diagnoses associated with improper management of treatment included:

Diagnoses that were each found in 3 percent of claims studied included cardiac arrest, congestive heart failure, cerebral artery occlusion with infarction, pneumonia, vascular insufficiency to intestine, nontraumatic hemoperitoneum, and respiratory arrest.

The factors identified by physician reviewers as contributing to patient harm for pulmonary embolism included inadequate patient assessments and selection and management of therapy. In one case, the hospitalist was alleged to have failed to order an insertion of an inferior vena cava filter. However, it was determined that the patient was too fragile to endure the procedure. In another case, the patient experienced an intracranial bleed. When a DVT was suspected, a doppler study was ordered, but the patient could not be placed on anticoagulants. The patient expired before the test could be performed. Both cases were dismissed.

In the cases of sepsis, there were questions about timely diagnosis and appropriateness of treatment. Physician reviewers noted failure to appreciate and reconcile relevant signs, symptoms, and test results, thus delaying interventions. In some of these cases, patients did not follow treatment plans.

In the acute myocardial infarction cases, it was noted that initial diagnoses were incorrect because the physicians failed to develop a differential diagnosis. In some cases, there was a delay in ordering diagnostic tests that would have facilitated a correct diagnosis.

Improper Medication Management Claims

The third driver of hospitalist claims was improper medication management. The factors that contributed to patient injury included:

Patient assessment issues included inadequate history and physicals and failure to appreciate and reconcile relevant signs, symptoms, and test results. Physician reviewers also cited failure or delay in ordering diagnostic tests.

Another factor in improper medication management was selection and management of therapy. This most often was related to failure to order medications or ordering medications that were contraindicated by other medications.

The third factor that impacted medication management was communication among providers regarding the patient’s condition. Communication failures were sometimes due to the failure to review the medical record or to inadequate handoffs. Important information was not communicated during transitions in care.

Causes of Patient Harm

Patient harm comes from a variety of causes. 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. There were examples of chronic conditions that were assumed to be the cause of current symptoms rather than the manifestation of a new disease entity.

The largest number of cases revealed weaknesses in systems and processes that were depended upon by nurses and physicians. Information can be difficult to locate in some electronic health records (EHRs) or obscured by lengthy progress notes resulting from copying and pasting over-documentation. On occasion, tests were not performed, or test results were not delivered, or reports were not received by treating physicians.

Communication between nurses and hospitalists sometimes failed. Handoffs between hospitals did not convey critical information, and efforts to reach physicians in other specialties were sometimes unsuccessful.

Top 10 Risk Mitigation Strategies for Hospitalists

The following strategies may help hospitalists avoid some of the issues uncovered by this study:

  1. Ensure effective handoff procedures during hospitalization and at discharge.
  2. Communicate with everyone involved in the patient’s care, including patient, family, prior-treating physician, and patient care team members.
  • Introduce yourself and your role.
  • Sit down and talk to the patient using their name and eye contact.
  1. Document your plan and rationale, including any changes in plan.
  • Be sure to document patient noncompliance.
  • Use quotes for patient comments related to noncompliance.
  1. Evaluate the need for physical examination when notified of a change in an inpatient’s condition.
  • If in doubt, go see the patient for a bedside evaluation.
  • Be mindful of what you tell nursing staff on the phone, as they will chart your exact comment with quotation marks.
  1. Always consider a differential diagnosis early in treatment.
  2. Follow up on all laboratory tests and procedure reports.
  • Review test and lab results that were not available prior to patient discharge.
  • Ensure notification of primary care physician and patient of abnormal results after discharge.
  1. Do not delay consultations or testing.
  • Be careful relying on curbside consultation and always consider asking the specialist to examine and evaluate the patient.
  1. Ask for a second opinion.
  • Advanced practice practitioners should consult supervising physician if needed.
  1. Documentation is your silent witness: Document clearly and completely in the patient medical record.
  • Know the approved abbreviation list for the facility, as they are not all the same.
  1. Review the medical record thoroughly. Understand facility EHR protocols and where to find information in the EHR.
  • If the patient was seen in the ER previously for related symptoms, review the ER record.
  • Ask for help from nursing staff if you cannot find something in the medical record.


In many ways, hospitalists provide essential functions in healthcare as the medical profession has specialized and subspecialized. Hospitalists provide coordination of care for hospitalized patients.

Providing care to large numbers of acutely ill patients exposes hospitalists to claims and lawsuits, some of which are primarily directed at other clinicians. There are things that hospitalists can do to reduce the chances of patients being harmed and hospitalists being named in claims or lawsuits.

Hospitalists provide the essential link between patients and specialists, and among a variety of clinicians. Teamwork requires effective working relationships, attention to important test results, communication of important information during handoffs, and comprehensive documentation.

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.