By John Palmer
A recent report from medical liability insurer Coverys indicates that primary care physicians (PCP) make a lot of diagnostic errors, leading to high malpractice payouts.
Coverys, a provider of medical professional liability insurance, released its second Red Signal Report, providing a data-driven look at the state of primary care in the United States. The series is designed to “identify the major risk factors, claims warning signals, and safety vulnerabilities within specific specialties and clinical areas where education and practice change initiatives can improve patient safety, reduce malpractice exposures, and increase reimbursements for providers.”
This new report analyzed 1,800 closed primary care–related medical professional liability claims at Coverys across a five-year period from 2013 to 2017. A previous report explored radiology claims data.
“The role of the primary care provider (PCP) has become increasingly challenging, with yesterday’s family doctor now accountable for all aspects of the patient care continuum,” said Robert Hanscom, vice president of business analytics at Coverys and a co-author of the report, in a written release. “This includes referral management, management of multi-morbidities, and transfer to long-term care, all while keeping a close eye on utilization, appropriate levels of care, and patient quality metric outcomes. This demanding environment is compounded by challenges including increased patient volumes with shorter office visits and unpredictable transitions of care. Anything but astute attention to every aspect of the patient journey can lead to unintended injuries and malpractice claims against the PCP.”
The report acknowledges that the role of the doctor has changed over the years, leading to an increased responsibility on the shoulders of the once-termed “family doctor”—and with that a higher risk of liability. According to the report, the traditional family physician would make house calls and perform a large array of clinical services, including the delivery of babies, while admitting, treating, and rounding on hospitalized patients.
Today, instead of a family doctor, there is the much more challenging primary care physician (PCP) role. The PCP is more responsible for all aspects of patient care, including management of referrals, multiple comorbidities, and transfers to long-term care, all while monitoring utilization, levels of care, and patient quality metrics. It’s a lot to juggle, and with mandates such as electronic health record (EHR) usage, increased patient volumes with shorter office visits, complicated medication management, and unpredictable transitions of care, there is an increased risk of mistakes and accompanying medical malpractice claims.
“Primary care physicians play a critical role in the delivery of a timely and accurate diagnosis, selection of treatment therapies, and the monitoring of high-risk medications,” said Robin Webster, senior risk consultant at Coverys and co-author of the report, in a release. “Failure to correctly assess patient conditions during these complex phases of care can result in significant patient harm.”
Some of the key findings of the report include the following:
Diagnostic errors. For PCPs, diagnostic errors were the leading type of claim (46%), accounting for the highest proportion of indemnity paid (68%). The top allegation for PCPs involved inadequate patient assessment. Ideally, this assessment would include a complete family history and a thorough physical exam.
Treatment claims. Medical treatment–related claims were the second most common allegation for PCPs, just over 20%. According to the report, these claims involve issues with care rendered from non-procedural therapies. They frequently are associated with cardiac treatments, pain management, wound care, and blood administration.
Medication claims. The most critical step in the medication process for PCPs is the monitoring of the patient’s medication regimen. These claims often result in high-severity injuries; this is especially the case when high-risk medications such as anticoagulants and opioids are not closely managed. The report found that roughly 45% of the medication-related claims and more than 50% of lawsuits paid were directly related to allegations of inattentive monitoring and management. Medication ordering was the second most frequent claim allegation, about 33% of the medication-related claims and 38% of the indemnity dollars.
Care transitions. The report found that when being transferred from one healthcare setting to another or to home, patients are vulnerable to unexpected issues when the clinical care team fails to communicate and hand off critical information related to patients’ care. Some of the biggest issues associated with transitions of care involved a delay or failure to obtain a specialty consult when clinically indicated (38%). Other issues included failure to coordinate follow-up care, communication breakdowns among multiple physicians who may be providing care to a single patient, failure to work as a cohesive clinical team, and a failure or delay in transferring to an alternative facility.
Recommendations for improvement
The report’s conclusion laid out a series of recommendations from Coverys that could lead to improved patient outcomes as well as lesser risk of liability.
Make sure patients are screened for cancer. The report authors concluded that diagnostic accuracy and treatment could be improved by regularly performing a complete age-appropriate history and physical exam on every patient that includes cancer screening. This screening is key, considering that some 50% of diagnosis-related claims involved a failure to diagnose cancer cases properly. In addition, the following items were recommended:
- Establish written cancer screening guidelines.
- Obtain and document a complete family history, including history of cancer (even if there is none, which should also be documented).
- Perform cancer-screening physical exams, unless deferred. Document all physical exams where cancer screening was deferred.
Close the referral loop. According to the report, many liability claims came from improper patient transitions, handoffs, discharges, and referrals to specialists when needed. The following changes were recommended:
- Use an EHR to track all ordered tests and consults.
- Engage patients in the referral process by providing relevant patient education materials as well as scheduling referrals and diagnostic tests performed outside the office setting.
- Set up policies to ensure practitioners review and document all consultant reports and test results received, including when results are received from outside their own EHR.
- Communicate all test results to patients. Consider secure messaging via a patient portal when communicating normal results.
Ensure safe care transitions take place. For many patients, a hospital discharge is just the end of one chapter of their care plan; it’s essential to ensure the next chapters play out as prescribed. The report offered the following recommendations:
- Provide written information when referring a patient for consultation, second opinion, or diagnostic test.
- Offer care coordination to patients who are identified as having complex medical conditions and/or social needs and/or being at high risk.
- Schedule follow-up appointments for patients with complex medical needs within 14 days of discharge home from a hospital.
Prescribe and administer medications safely. As stated in the report, medication errors continue to be one of the biggest patient safety risks in U.S. hospitals. With drug diversion and opioid abuse continuing to rise, it’s crucial to maintain a safe medication program. The report recommended the following:
- Develop and implement a process for obtaining informed consent when medications with a known degree of high risk are prescribed or administered.
- Develop and implement a formal medication reconciliation process.
- Use an EHR e-prescribing module with clinical decision support.
- Comply with state regulations regarding the administration of injections by unlicensed assistive personnel.
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at firstname.lastname@example.org.