MPL Case Studies Aligned with Top Diagnostic Risks

A recent article published by the Society to Improve Diagnosis in Medicine (SIDM) notes that one-third of medical malpractice cases with serious injuries (including death) allege diagnostic errors.

In particular, missed or delayed diagnosis of vascular events, infections, and cancers are the most common. The SIDM article is based on analyses of medical professional liability (MPL) cases in CRICO’s Comparative Benchmarking System (CBS) database.

For individual clinicians, being named in an MPL case remains a relatively rare event (fewer than 4 of 100 physicians per year). One way clinicians can better understand how breakdowns in the diagnostic process can lead to allegations of malpractice—and what opportunities they might have to improve patient safety in their practice setting—is by reading or listening to case studies from that same CBS database.

A selection of cases is listed below, which includes specific recommendations for patient safety improvement that align with the key areas of vulnerability outlined in the SIDM article.

• Lung Cancer
  Am I Sure My Patient Got The Test I Ordered?
• Breast Cancer
  Should I Use a Decision Support Tool?
• Colorectal Cancer
  Unresolved Symptoms and Delayed Colon Cancer Diagnosis
• Prostate Cancer
  Patient Unaware of PSA Testing, Then Cancer
• Stroke
  Poor Triage of Stroke Patient Closes Opportunity Thrombolytics
• Myocardial Infarction
  Missing an MI When Symptoms Didn’t Match Diagnosis
• Aortic Dissection
  Diagnosis of Aortic Dissection Delayed by Mismanagement of Imaging Orders
• Thromboembolism
  Lack of Appreciation for Patient’s H & P Led to Missed PE
• Sepsis
  Young Man Dies from Flu After ED Discharge
• Meningitis
  Failure to Rule Out Bacterial Meningitis
• Pneumonia
  Misread X-ray Leads to Respiratory Failure
• Endocarditis
  Test Results from ED Not Relayed to Patient in Time

Of course, two-thirds of serious injury MPL cases stem from other aspects of care. The CRICO library of case studies covers many of those areas as well.

For audio case studies, CRICO has an on-going podcast, “MedMal Insider,” and CME Podcast Bundles, which are prepackaged sets of content for which you may earn 0.5 Risk Management Category 1 Study in Massachusetts.