Medical Malpractice Bulletin – October, 2015

Perspective: Diagnostic Errors – SIDM works to eliminate them
By Charles A. Pilcher MD FACEP”
October, 2015

On September 27-29 I joined over 300 other healthcare professionals in Washington DC for an international conference on “Diagnostic Error.” This is an annual event sponsored by the Society to Improve Diagnosis in Medicine (SIDM). Among dozens of fascinating presentations which I will cover in future issues of this Bulletin, the one that made the biggest impression was by Dr. Amanda Walker of the “Clinical Excellence Commission” of New South Wales, Australia, on their “Take 2 – Think – Do” campaign. All of us in medicine who study diagnostic error are aware of the importance of “critical thinking” and “self-awareness.” Dr. Walker and her team have boiled down this concept to a succinct “recipe” for success. Continue reading -> 

IOM report on “Diagnostic Errors”: Most of us will experience a diagnostic error in our lifetime
That was the headline for most of the media coverage of last month’s release of the IOM Report on “Reducing Diagnostic Errors.” The report estimates that such errors affect at least 12 million adults each year. The authors also emphasize the importance of medical education reform to include training on reducing such errors by emphasizing clinical reasoning, teamwork, communication and diagnostic testing. [Editor’s Note: We need smarter diagnostic testing, not more diagnostic testing. Also, we need to develop better ways to learn from our mistakes, as all of us in the field of medical malpractice recognize. That is why the SIDM conference on diagnostic error was so refreshing. /CP] Download the full IOM report here.

Incidental findings on chest CT angiograms are common, need follow-up
A study in the American Journal of Emergency Medicine of 370 emergency chest CT angiograms ordered to rule out aortic dissection found only 46 dissections (only 19 of them new) but 329 incidental findings. Of those, 106 incidental findings included recommendations for followup, 47 of which were for pulmonary nodules of possible clinical significance. Only 30 of the 106 recommendations were acted upon, mostly related to the pulmonary nodules. [Editor’s Note: There appears to be considerable room for improvement, or at least for documenting why an incidental finding is not being addressed. /CP]

Single “high-sensitivity troponin test” rules out MI – most of the time
Shah et al. published a study in Lancet of 6304 patients in whom a “high-sensitivity troponin test” was used to rule out acute MI. The study claims to be 99.6% accurate at predicting the patient is NOT having an MI (i.e., “at very low risk”) if the troponin level is under 5ng/l. As expected, the lead author has acted as a consultant for the developer of the test, Abbott Laboratories, but a neutral cardiologist reviewer, Dr. Sripal Bangalore, calls the findings “pretty interesting and compelling,” and added “the test is not perfect and some people who are having heart attacks will be missed… The test must remain one element of an overall physician evaluation of chest pain.” The test (which costs about $15) is slightly less reliable if done within 2 hours of the onset of symptoms, and at this time is only available in Europe. [Editor’s Note: Even if a test is 100% accurate at ruling out a condition, it does not solve the patient’s problem. Chest pain can be caused by far more conditions than a heart attack. Too many med mal cases arise because physicians fail to look at the other possibilities, primarily pulmonary embolism and aortic dissection. /CP]

Insurer’s quality review documents are open to attorneys in Pennsylvania
Blue Cross of NE Pennsylvania (BENP) was required to turn over records of its investigation into the care rendered by one of their insureds against whom a malpractice case was filed. BENP claimed that its review records were protected by provisions of Pennsylvania’s “Peer Review Act.” However, the Act only protects quality of care reviews of records of health care providers.  Thus, the court ruled that, “A corporation that provides health insurance and not medical care, is not a professional care provider” and is not conducting “peer review,” when reviewing records for quality. Thus any review conducted by a health insurer is not confidential.

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