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Rise in missed diagnoses claims puts radiology on notice

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Missed diagnoses are increasingly becoming a major source of medical professional liability claims, with radiologists particularly vulnerable to claims of malpractice, but implementation of risk management practices could reduce such exposures, experts say.

Diagnosis-related failures are the single largest root cause of claims at 33%, resulting in indemnity payments slightly higher than the next five highest categories combined, according to a white paper published in March by Boston-based medical professional liability insurer Coverys.

“It’s fair to say diagnosis is our biggest and most challenging problem area through the lens of medical professional liability claims,” said Robert Hanscom, vice president of business analytics for Coverys. “Other target areas like surgery and obstetrics and medication error have all shown some improvement over the last decade, but diagnosis has not. Frequency has probably gone up to some degree, and certainly the clinical severity of those cases and the outcomes have worsened.”

Missed diagnosis was responsible for the second-highest number of medical professional liability claims, after performing surgery, according to information compiled by the Medical Professional Liability Association, the trade association representing medical professional liability insurers, risk retention groups, captives, trusts and other entities, said Brian Atchinson, president and chief executive officer of the Rockville, Maryland-based association.

“That’s fascinating simply because that’s in many instances where the human element comes into play, for all the great uses of technology and modern science and modern medicine,” he said.

Radiologists are involved in 15% of diagnosis-related medical malpractice claims, second only to those of general medicine health care providers, according to an analysis of closed claims published by Coverys last week. Claims naming a radiologist — totaling 595 in 2013-2017 — often involve significant patient harm and most frequently allege an incorrect or delayed diagnosis of a patient’s condition, according to the report. Of the claims against radiologists, 80% of the missed diagnoses are alleged to have resulted from the misinterpretation of clinical tests.

“There are some (radiologists) that are very sharp in reading the images and interpreting them,” Mr. Hanscom said. “Those skills may differ from radiologist to radiologist. This is where the work that radiology has done to try to create a peer review environment where they are routinely checking one another’s (interpretations) … is really important work. We’re urging a continued press on that front because that’s one of the key ways to level out that variability and to try to make sure radiologists are really benefiting from one another’s expertise.”

More than 80% of missed diagnosis claims involved permanent injuries to the patient or death, according to the report.

Radiologists are exposed to potentially high claims emerging from “unquestionably devastating” results such as a woman with ovarian cancer forced to undergo a hysterectomy and unable to have children, said Jeffrey Levy, Houston-based vice president of national health care practice for USI Insurance Services L.L.C. “Because you’ve got a horrible result, the presumption is that the doctor has done something wrong, even if they read the test result correctly or the test result did not show there was any abnormality,” he said.

Successful radiology claims, although not quite as expensive as “bad baby” claims, can be costly, said Bruce Whitmore, senior vice president and senior resource consultant for global captive/national health care practices with Willis Towers Watson P.L.C. Tampa, Florida. For example, a missed cancer diagnosis for someone making $150,000 per year multiplied by the 10 career years that the person is unable to work could result in an award of $1.5 million in compensatory damages.

“The numbers can compound pretty quickly on a failure to diagnose claim,” he said. “Those kinds of claims are also heavy from an emotional point of view on a jury.”

The Coverys report recommended a series of risk management steps for the radiology profession, including the development of criteria to determine whether a second read of a film must be performed and the time frame for completion and confirmation back to the radiologist that the second read has been received. It also suggested the implementation of checklists that can help circumvent some cognitive biases and decrease reliance on memory, the revision of standards to keep pace with technology changes, and revisiting peer review practices to ensure they address how to measure and communicate periodic evaluation of clinical outcomes and compliance with established quality indicators and when performance may warrant closer review.

“The best practices are out there,” Mr. Hanscom said. “But I think it’s true with radiology, as it’s true with every other specialty in health care, there’s no mandate to actually engage in these best practices.”

The focus on missed diagnosis does not mean the traditional sources of medical malpractice claims such as obstetricians/gynecologists are no longer a concern, experts say. Coverys is planning to publish a white paper on obstetrics later this year, Mr. Hanscom said.

OB/GYNs are the most likely to be sued at least once, with 63.6% reporting they had been sued once, 44.1% reporting they had been sued at least twice, and the number of claims per 100 physicians at 162 for OB/GYN practitioners in 2016, according to a series of reports published by the American Medical Association in December and January.

“The delivery of babies, while the vast majority go fine, that is an area where when there are claims, they can be quite severe,” Mr. Atchinson said.

For example, a Pennsylvania judge issued the largest medical malpractice award in state history at $47 million in March 2018 to a child disfigured in a post-birth procedure, according to a statement issued by the Kline & Specter P.C., which represented the child’s family against Johnston, Pennsylvania-based Conemaugh Memorial Medical Center and one of its physicians. A hospital system spokesperson could not be reached for comment.

“The markets still continue to charge substantially large premiums to OBs, neurosurgeons (and) orthopedic surgeons,” Mr. Whitmore said. “Those are the kinds of specialties that garner a much larger premium, both due to claims frequency but also claims severity. Radiology has historically been lower down on the list, although when a claim goes bad on a radiologist it can go pretty badly.”