Missed Diagnoses Trigger Primary Care Malpractice Claims

Troy Brown

July 18, 2013

Most malpractice claims against primary care physicians are a result of missed diagnoses, especially of cancer and myocardial infarction in adults and meningitis in children, and medication errors, according to an analysis of data from 34 published studies of malpractice claims.

Emma Wallace, MB Bch, BAO, a clinical research fellow in the Health Research Board Centre for Primary Care Research at the Royal College of Surgeons in Ireland Medical School in Dublin, and colleagues report their findings in an article published online July 18 in BMJ Open.

"This review is timely considering the increasing interest in focusing on primary care as a way of improving patient safety," the authors write. They note that although malpractice claims may not be a representative measure of adverse events, they can provide insight into the types and sources of adverse events. Other specialties have used such information to identify "higher risk domains of practice."

Of the 34 studies reviewed, almost half (15) were based in the United States, 9 in the United Kingdom, 7 in Australia, 1 in Canada, and 2 in France.

The most common cause of malpractice claims was missed or delayed diagnosis, which accounted for 26% to 63% of all claims in the studies reviewed. Death was the most frequent patient outcome recorded, occurring in from 15% to 48% of claims.

Errors leading to malpractice claims were often multifactorial in nature: 1 study reported that in 43% of errors, 2 or more clinicians were involved in the missed diagnosis, and in 16% of errors, 3 or more clinicians were involved. The most frequent processes cited in delayed or missed diagnosis included failure to obtain a diagnostic test, develop an adequate follow-up plan, obtain a complete history, or do a physical examination, as well as misinterpretation of a diagnostic test.

In adults, results were similar across studies regarding the most frequent missed or delayed diagnosis, with cancer (breast, colon, melanoma, lung, and female genital tract) and the circulatory system (myocardial infarction) at the top. Appendicitis, ectopic pregnancy, and fractures were also common.

In children, meningitis and cancers were the most frequent missed or delayed diagnoses. A UK study of pediatric meningitis cases showed that both individual (poor documentation and deficiencies in management including inadequate safety-netting) and systems errors (poor practice cross-communication and inadequate contingency planning for emergencies in appointment systems) factors were involved.

Medication error was the second most frequent medical occurrence cited in claims and accounted for 5.6% to 20% of claims.

Many claims were unsuccessful. In the United States, the largest study (27,000 resolved claims) found that less than one third (31.9%) ended in payment, and in 2 other studies, the figures were 28% and 20%. In the United Kingdom, about half of malpractice claims resulted in payment.

One US review of almost 5000 family practice claims found mean payments of $253,739.69 and median payments of $199,389.20. In Australia, 15% of total paid claims were upward of $250,000. A UK report found that malpractice claims for general practitioners were rising, with 13 claims resulting in payments in excess of £1 million.

The annual prevalence of malpractice claims in the United States has remained stable during the last 20 years, but the number of claims against general practitioners in the United Kingdom and Australia has been rising.

"[I]t is difficult to generalise results across countries," the authors write. "In the USA, the term 'primary care' often includes internal medicine, general paediatrics and family practice, while in the UK the term is more specific to general practice."

The consequences of malpractice litigation are not only monetary, the authors note. Physicians who have had claims brought against them may practice "defensive medicine," which can result in overdiagnosis and overtreatment. The process is also very upsetting for physicians: a study found that one third of physicians with claims against them considered leaving medicine or retiring early.

This work is supported by the Health Research Board (HRB) of Ireland through the HRB Centre for Primary Care Research. The authors have disclosed no relevant financial relationships.

BMJ Open. Published online July 18, 2013. Full text

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