This document summarizes a study examining hospitalist malpractice claims. The study analyzed 464 malpractice claims against hospitalists between 2007-2014. It found that 78% of claims fell into three categories: diagnostic errors (36%), treatment errors (31%), and medication errors (11%). Multiple factors contributed to these errors, including inadequate patient assessment (35%), breakdowns in provider communication (23%), and issues with therapeutic interventions (16%). Examples are provided to illustrate how failures in these areas led to patient injuries or death. The document concludes with recommendations on how hospitalists can improve patient management to help mitigate risks.

1. Study Examines
Hospitalist Malpractice
Claims
By Floyd Arthur

2. On the front lines of acute
care medicine,
hospitalists work under
circumstances that are

3. far from ideal. Not only
are they directly
responsible for multiple
patients with complex

4. medical needs, they are
often forced to accept
patient loads that they
identify as unsafe.

5. Hospitalist Malpractice
Claims

6. According to a 2013
survey of 890
hospitalists published in
JAMA Internal Medicine,
40

7. percent of hospitalists
report carrying an unsafe
patient load at least once
a month. Over

8. 35 percent report unsafe
patient loads more than
once a week. According
to the doctors

9. themselves, this leads to
communication failures
and diagnostic and
treatment errors

10. that often result in
significant harm.

11. Allegations In Hospitalist
Malpractice Claims

12. Hospitalists are not sued
more often than
physicians in any other
speciality. However,

13. malpractice claims
against hospitalists often
involve serious injuries
or death. In an

14. attempt to identify
practice patterns that
result in the most serious
patient injuries, The

15. Doctors Company
analyzed medical
malpractice claims
against its 2,100 member

16. hospitalists that closed
between 2007 and 2014.
All claims, regardless of
outcome, were

17. included in the analysis.
A total of 464 claims were
reviewed.

18. A review panel of
physician experts
examined the claims and
categorized them based
on

19. the nature of the
allegations. Seventy-
eight percent fell into
three categories:
diagnostic

20. errors (36 percent);
treatment errors (31
percent); and
medication-related
errors (11 percent.)

21. The remaining categories
were improper
performance, such as
improperly placed

22. central venous catheters,
(5 percent); delay in
treatment (3 percent);
and failure to

23. monitor patient status (3
percent).

24. Factors Contributing to
Hospitalist Malpractice
Claims

25. Multiple factors were
identified as contributing
to the majority of
hospitalist malpractice

26. claims.. Seventy-four
percent of these were in
three main categories:
patient

27. assessment, provider
communication and
therapeutic
interventions.

28. Patient Assessment

29. Thirty-five percent of the
diagnostic and treatment
errors identified in the
study were

30. due to inadequate patient
assessment, including:

31. * Failure to establish a
differential diagnosis

32. * Failure or delay in
ordering diagnostic tests

33. * Failure to consider
available information
(e.g. lab values,
observations, signs and
symptoms)

34. Example 1: A 20-year old
female was admitted
through the ER with a
history of fever,

35. chills and pain radiating
from her back to her right
side. A chest X-ray
showed a right

36. lower lobe infiltrate; her
oxygen saturation was 86
to 89 percent, and blood
work

37. revealed elevated D-
dimers.

38. The hospitalist put the
patient on IV antibiotics
for a diagnosis of
pneumonia and

39. ordered pulmonary and
infectious disease
consults. Later, the
patient became

40. disoriented and
complained of increasing
shortness of breath. She
died soon afterwards.

41. The cause of death was a
pulmonary embolus.

42. The hospitalist’s failure
to consider the elevated
D-dimers, include PE in
the differential

43. diagnosis and order
further diagnostic tests
were identified as factors
that contributed to her
death.

44. Provider Communication

45. Breakdowns in
communication between
nursing staff, consulting
physicians and the

46. hospitalist were
identified as a factor in
23 percent of medical
malpractice claims.
These

47. included nurses failing to
notify the responsible
hospitalist of important
clinical findings

48. and physicians failing to
note findings mentioned
in the patient’s chart.

49. Example 2: A 49 year-old
male was admitted
through the ER with chest
and back pain,

50. headache, and numbness
and tingling in his lower
extremities. On
admission the blood

51. pressure in his right arm
was 154/53; it was 117/56
on the left. The nurse
failed to

52. document this
discrepancy in the
medical record or bring it
to the attention of the

53. hospitalist. The patient
was discharged and
subsequently collapsed
and died at home.

54. The cause of death was
mediastinal hemorrhage
due to an aortic
dissection.

55. The lack of
communication between
the nursing staff and the
hospitalist were
identified

56. as critical factors in the
patient’s death.

57. Therapeutic
Interventions

58. In 16 percent of the
malpractice claims
reviewed, the
hospitalist’s choice of
therapy was

59. identified as a factor in a
patient’s injury or death.
This category included
improper

60. selection of appropriate
therapy; failure to order
appropriate medications;
ordering

61. inappropriate
medications; and
ordering no medication
at all. Breakdowns in

62. communication between
providers, patients and
families and nursing staff
were also a

63. factor in several of these
claims.

64. Example 3: A 75 year-old
female was admitted to
the hospital with a
diagnosis of

65. pneumonia and
uncontrolled Type 2
diabetes. The hospitalist
treated her pneumonia

66. appropriately and placed
her on a sliding-scale of
regular insulin and
Lantus. Two days

67. later, as the patient’s
pneumonia was
improving, a second
hospitalist took over her
care.

68. He changed her insulin to
twice daily Humalog, after
which she experienced
several episodes of

69. hypoglycemia. The
patient subsequently
arrested and died. Her
last blood glucose was 15
mg/dL.

70. The panel identified the
failure of the nursing
staff to adequately
communicate the
patient’s

71. repeated episodes of
hypoglycemia to the
hospitalist as well as the
hospitalist’s decision to

72. change her insulin
without consulting an
endocrinologist as
factors in the patient’s
death.

73. Advice for Hospitalists:
Strategies for Managing
Risk

74. In its assessment of the
above findings, the
physician panel
identified “weaknesses
in

75. the systems and
processes used by
members of the
healthcare team” as a
major

76. contributor to
preventable errors that
result in significant
patient harm. These

77. undoubtedly include
staffing shortages,
unpredictable patient
census, and unwieldy

78. electronic health records
that make important
clinical information
difficult to find.

79. Nonetheless, the study
reveals some areas
where physicians can
improve patient

80. management and
mitigate the risks
inherent in the
hospitalist’s role. Some

81. recommendations from
the panel include:

82. * Order diagnostic tests
promptly and involve
other specialties early
when the differential

83. includes diagnoses that
have the potential to
result in serious harm.

84. * Build rapport with
patients early in their
hospital stay.

85. * Understand that the
hospitalist’s role is to
integrate and coordinate
patient care.

86. * Remain accessible to
nursing staff and
consulting services
throughout the patient’s
hospital stay.

87. * Review all
documentation carefully
and question information
that is unclear.

88. * Be cognizant of
emerging pathology,
especially when the
differential includes a
number of similar
diagnoses.

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