Diagnostic Mistakes a Big Contributor to Malpractice Suits, Study Finds

Diagnostic errors aren’t just an ethical issue and a danger to patients — they’re also a big liability issue for doctors, said Dana Siegal, RN, at a conference on misdiagnosis Tuesday hosted by the Iowa Healthcare Collaborative.

Siegal discussed a study of medical liability claims nationwide from the databases of more than 20 captive and commercial liability insurers during the years 2014 to 2018, performed by CRICO Strategies, a medical liability insurer. The study found that of 50,328 closed cases, the diagnosis-related cases had an average gross indemnity payment of about $494,000, second only to ob/gyn-related cases, which had an average payment of $902,000, said Siegal, who is director of patient safety services at CRICO in Boston.

However, even though they had a lower average payment, the diagnosis-related cases had a higher total payout: $1.74 billion compared with $838 million for the ob/gyn cases — and the number of cases was far higher, at 8,922 cases compared with 2,053 ob/gyn cases, Siegal said. Of the diagnosis-related cases, 39% were closed with an indemnity payment, second again only to ob/gyn cases, at 45%.

“We make errors for a reason, and my job is focused solely on trying to understand the reasons behind the error” involved in cases such as these, said Siegal — “and many of them are pretty visible.”

One problem is that “healthcare is inherently risky,” she continued. For example, “there’s ever-changing industry knowledge, growing bodies of clinical options, new diseases, and new technology. There are variable work demands — boy, didn’t we experience that this past year! — and production pressure has long been a struggle and a challenge for our providers and their teams.” Not to mention variable individual competency, an aging population, complex health issues, and evolving workforces.

Siegal referred to a recent wrong-site surgery case in which a man in Austria had the wrong leg amputated. “We have been talking about wrong-site surgery for years, and yet it still happens,” she said. “So we’ve got a ways to go to get a handle on diagnosis, which is much younger in the maturity of understanding how to attack it. But if we don’t study the history, if we don’t study what’s available to us from the past, we’re not going to be able to impact the future.” She noted that investigations are often done in many other occupational mishaps, including airline crashes and industrial accidents, “so it’s a simple leap to say if we do that in every other industry, why not healthcare?”

In terms of malpractice cases, the vast majority of those surrounding a wrong diagnosis — 86% — involve a challenge around clinical judgment, the study found. In addition, of the diagnosis-related cases, “we actually found out that in 37% of these cases, there was a failure or delay to order a diagnostic test that in hindsight appeared to have been relevant in the moment, could have been helpful, or might have changed the outcome of the journey,” she said. In addition, 36% of cases involved the failure to appreciate and reconcile a relevant sign, symptom, or test result.

“Please understand that as we look at the data, we fully recognize that this is hindsight, and by the time we receive it, we have the entire journey,” said Siegal. “So this is not meant to be an edict, or a judgment that … the provider failed, or the team failed. What we’re saying is we have an opportunity to look back at how many times a particular test — sitting or living in a particular kind of setting, scenario, or set of symptoms — may be beneficial. And if we raise awareness about that, if we focus on that, we might be able to change the story going forward.”

Testing and test processing are also at issue in many malpractice cases, but surprisingly, getting the test results sent to the provider is rarely an issue. “In these [studied] cases, only 5% were impacted by a test result that did not reach the provider,” Siegal said. “However, 23% of them were impacted where the physician missed following up with the patient on some subsequent conversation. So while we often think it’s missing test results, really the communication between the provider and the patient becomes a primary focus of vulnerability, as does the communication in the referral process.”

Cognitive biases can also trigger diagnostic errors, Siegal said. “Anchor bias” occurs when “a provider anchors on a diagnosis, early on, and then through the course of the journey looks for things to confirm that diagnosis. Once they’ve confirmed it enough that ‘search satisfaction’ is met, that leads to premature closure” of the patient’s case. But that causes a problem because “it means that there’s a failure to continue exploring other options. What else could it be? It’s a failure to establish, perhaps, every differential diagnosis.”

To avoid this problem, providers “always want to think about, ‘Am I anchoring too soon? Am I looking to confirm, rather than challenge, my diagnosis?'” she said. According to the study, 25% of cases didn’t have evidence of a differential diagnosis, and 36% fell into the category of “confirmation bias” — “I was looking for things to confirm what I knew, but there were relevant signs and symptoms or positive tests that were still present that didn’t quite fit the picture, but it was close. So they were somehow discounted, and the premature closure took over and a diagnosis was made,” she said.

She suggested that clinicians take a “diagnostic timeout” — similar to a surgical timeout — when they’re arriving at a diagnosis. “What else could this be? Have I truly explored all the other possibilities that seem relevant in this scenario and, more importantly, what doesn’t fit? Be sure to dis-confirm as well.”