Failure to diagnose continues to be the top allegation against most specialties in medical malpractice litigation. Allegations can include missed diagnosis, delayed diagnosis or incorrect diagnosis, all of which can affect the patient's treatment plan and prognosis.

Improving Diagnosis in Healthcare, a landmark report by the National Academies of Sciences, Engineering and Medicine, found that diagnostic errors were the costliest type of malpractice claims, and patients who experienced a diagnostic error were twice as likely to die than those patients who filed lawsuits with other types of allegations.¹

In reviewing closed cardiology malpractice claims, The Doctors Company identified missed or delayed diagnosis of myocardial infarction (MI) as a top allegation.

Case Example

In this cardiology case, the estate of a patient alleged that a delayed diagnosis and treatment of an acute MI resulted in worsening heart damage, congestive heart failure (HF) and death. The named defendants were a cardiologist and group practice, two emergency medicine physicians and group practice, and a nurse practitioner (NP) and supervising physician.

The patient's history was significant for hypertension, smoking and chronic obstructive pulmonary disease. The patient presented to the primary care physician and was seen by the NP with complaints of neck, chest and abdominal pain; headaches; and extremity numbness and weakness. A chest radiograph taken that day showed vascular congestion with interstitial edema and normal heart silhouette. The differential diagnosis included acute cardiopulmonary edema vs. noncardiogenic pulmonary edema. The NP diagnosed cervicalgia and sent the patient home.

Two days later, the patient was transported to the local emergency department (ED) after complaining of a two-day history of sharp midsternal chest pain radiating to both shoulders. The ECG reflected Q waves suggestive of an older infarction. The ED physician diagnosed unstable angina. At shift change 30 minutes later, a second ED physician saw the patient, ordered a cardiology consult and admitted the patient.

The cardiologist first saw the patient in the late morning. The elevated troponin levels suggested an NSTEMI. Standard therapy was begun, and the cardiologist documented an intention to evaluate the troponin trend and recommended performing cardiac catheterization and coronary angiography the following day unless the patient's symptoms warranted earlier intervention.

The patient's condition deteriorated over the day, and an urgent left heart catheterization and coronary angiogram were performed by the cardiologist later that evening (12 hours after admission). The left anterior descending artery was found to have a proximal 100% occlusion with concern for possible thrombus. One bare-metal stent was placed. The left ventricular ejection fraction was 30-35%.

Over the next few weeks, the patient had a difficult hospital postprocedural course. A subsequent discharge to a rehabilitation facility was equally complicated. One month later, the patient was transported and admitted to the hospital with heart and respiratory failure and died one week later of disseminated intravascular coagulation, congestive HF and respiratory failure. A postmortem examination was not performed. The case was resolved on behalf of the cardiologist.

Case Discussion

The plaintiff alleged that all defendants deviated from the standard of care by failing to timely diagnose and treat the patient's acute coronary syndrome, leading to a premature death.

The two emergency medicine physicians and their group were dismissed after defense experts supported their care, stating they were reasonable in obtaining a timely cardiology consultation.

Defense experts were not supportive of the NP, who failed to further explore cardiac issues and did not send the patient to the ED or consult with the supervising physician. The NP, who was not the target defendant, was ultimately dismissed from the lawsuit. Instead, a specific allegation was made against the cardiologist, who was the target defendant. The allegation was failing to promptly take the patient to surgery when the patient experienced an NSTEMI. Three defense experts agreed with that allegation and were unable to support the cardiologist for failing to take the patient to the catheterization laboratory sooner.

Risk Management Strategies

The following strategies can help medical professionals improve their quality of care and reduce liability exposure and risk of malpractice litigation.

• Stay current with the ACC and American Heart Association (AHA) clinical practice guidelines, recommendations and established standard of care. In this case, given the patient's ongoing symptoms and recent evidence of HF, the standard of care would have been to perform the cardiac catheterization, coronary angiography and PCI procedures within two to four hours of admission.²
• Appreciate and reconcile relevant signs, symptoms and test results. The NP did not understand the severity of the patient's complaints and condition and failed to refer the patient for emergent care, perform a 12-lead ECG, or seek advice from the supervising physician.
• Consider atypical cardiovascular disease presentation for women. Cardiovascular disease remains the leading cause of mortality in women in the U.S. yet continues to be underdiagnosed and undertreated. Women are more likely to have a worse health status than men at the time of their acute coronary event. Smoking, diabetes, depression and anxiety may be stronger risk factors among women compared with men.³
• Be familiar with and understand the litigation process. For more information, Click here to read a recent article in Cardiology titled, "Understanding the Medical Malpractice Litigation Process."

References

1. Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine; Balogh EP, Miller BT, Ball JR, eds. Improving Diagnosis in Health Care. National Academies Press. 2015 Dec 29. Available here.
2. Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. J Am Coll Cardiol 2022;79:e21-e129.
3. Keteepe-Arachi T, Sharma S. Cardiovascular disease in women: understanding symptoms and risk factors. Eur Cardiol 2017;12:10-13.

Keywords: Cardiology Magazine, ACC Publications, Malpractice, Missed Diagnosis, Delayed Diagnosis, Myocardial Infarction, Delivery of Health Care