On the front lines of acute care medicine, hospitalists work under circumstances that are far from ideal. Not only are they directly responsible for multiple patients with complex medical needs, they are often forced to accept patient loads that they identify as unsafe.
According to a 2013 survey of 890 hospitalists published in JAMA Internal Medicine, 40 percent of hospitalists report carrying an unsafe patient load at least once a month. Over 35 percent report unsafe patient loads more than once a week. According to the doctors themselves, this leads to communication failures and diagnostic and treatment errors that often result in significant harm.
Hospitalists are not sued more often than physicians in any other speciality. However, malpractice claims against hospitalists often involve serious injuries or death. In an attempt to identify practice patterns that result in the most serious patient injuries, The Doctors Company analyzed medical malpractice claims against its 2,100 member hospitalists that closed between 2007 and 2014. All claims, regardless of outcome, were included in the analysis. A total of 464 claims were reviewed.
A review panel of physician experts examined the claims and categorized them based on the nature of the allegations. Seventy-eight percent fell into three categories: diagnostic errors (36 percent); treatment errors (31 percent); and medication-related errors (11 percent.)
The remaining categories were improper performance, such as improperly placed central venous catheters, (5 percent); delay in treatment (3 percent); and failure to monitor patient status (3 percent).
Multiple factors were identified as contributing to the majority of hospitalist malpractice claims.. Seventy-four percent of these were in three main categories: patient assessment, provider communication and therapeutic interventions.
Patient Assessment
Thirty-five percent of the diagnostic and treatment errors identified in the study were due to inadequate patient assessment, including:
Example 1: A 20-year old female was admitted through the ER with a history of fever, chills and pain radiating from her back to her right side. A chest X-ray showed a right lower lobe infiltrate; her oxygen saturation was 86 to 89 percent, and blood work revealed elevated D-dimers.
The hospitalist put the patient on IV antibiotics for a diagnosis of pneumonia and ordered pulmonary and infectious disease consults. Later, the patient became disoriented and complained of increasing shortness of breath. She died soon afterwards. The cause of death was a pulmonary embolus.
The hospitalist’s failure to consider the elevated D-dimers, include PE in the differential diagnosis and order further diagnostic tests were identified as factors that contributed to her death.
Provider Communication
Breakdowns in communication between nursing staff, consulting physicians and the hospitalist were identified as a factor in 23 percent of medical malpractice claims. These included nurses failing to notify the responsible hospitalist of important clinical findings and physicians failing to note findings mentioned in the patient’s chart.
Example 2: A 49 year-old male was admitted through the ER with chest and back pain, headache, and numbness and tingling in his lower extremities. On admission the blood pressure in his right arm was 154/53; it was 117/56 on the left. The nurse failed to document this discrepancy in the medical record or bring it to the attention of the hospitalist. The patient was discharged and subsequently collapsed and died at home. The cause of death was mediastinal hemorrhage due to an aortic dissection.
The lack of communication between the nursing staff and the hospitalist were identified as critical factors in the patient’s death.
Therapeutic Interventions
In 16 percent of the malpractice claims reviewed, the hospitalist’s choice of therapy was identified as a factor in a patient’s injury or death. This category included improper selection of appropriate therapy; failure to order appropriate medications; ordering inappropriate medications; and ordering no medication at all. Breakdowns in communication between providers, patients and families and nursing staff were also a factor in several of these claims.
Example 3: A 75 year-old female was admitted to the hospital with a diagnosis of pneumonia and uncontrolled Type 2 diabetes. The hospitalist treated her pneumonia appropriately and placed her on a sliding-scale of regular insulin and Lantus. Two days later, as the patient’s pneumonia was improving, a second hospitalist took over her care. He changed her insulin to twice daily Humalog, after which she experienced several episodes of hypoglycemia. The patient subsequently arrested and died. Her last blood glucose was 15 mg/dL.
The panel identified the failure of the nursing staff to adequately communicate the patient’s repeated episodes of hypoglycemia to the hospitalist as well as the hospitalist’s decision to change her insulin without consulting an endocrinologist as factors in the patient’s death.
In its assessment of the above findings, the physician panel identified “weaknesses in the systems and processes used by members of the healthcare team” as a major contributor to preventable errors that result in significant patient harm. These undoubtedly include staffing shortages, unpredictable patient census, and unwieldy electronic health records that make important clinical information difficult to find.
Nonetheless, the study reveals some areas where physicians can improve patient management and mitigate the risks inherent in the hospitalist’s role. Some recommendations from the panel include:
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