An Epidemiologic Study of Closed Emergency Department Malpractice Claims in a National Database of Physician Malpractice Insurers

Abstract

OBJECTIVES: The objective was to perform an epidemiologic study of emergency department (ED) medical malpractice claims using data maintained by the Physician Insurers Association of America (PIAA), a trade association whose participating malpractice insurance carriers collectively insure over 60% of practicing physicians in the United States. METHODS: All closed malpractice claims in the PIAA database between 1985 and 2007, where an event in an ED was alleged to have caused injury to a patient 18 years of age or older, were retrospectively reviewed. Study outcomes were the frequency of claims and average indemnity payments associated with specific errors identified by the malpractice insurer, as well as associated health conditions, primary specialty groups, and injury severity. Indemnity payments include money paid to claimants as a result of settlement or court adjudication, and this financial obligation to compensate a claimant constitutes the insured's financial liability. These payments do not include the expenses associated with resolving a claim, such as attorneys' fees. The study examined claims by adjudicatory outcome, associated financial liability, and expenses of litigation. Adjudicatory outcome refers to the legal disposition of a claim as it makes its way into and through the court system and includes resolution of claims by formal verdict as well as by settlement. The study also investigated how the number of claims, average indemnity payments, paid-to-close ratios (the percentage of closed claims that resolved with a payment to the plaintiff), and litigation expenses have trended over the 23-year study period. RESULTS: The authors identified 11,529 claims arising from an event originating in an ED, representing over $664 million in total liability over the 23-year study period. Emergency physicians (EPs) were the primary defendants in 19% of ED claims. The largest sources of error, as identified by the individual malpractice insurer, included errors in diagnosis (37%), followed by improper performance of a procedure (17%). In 18% of claims, no error could be identified by the insurer. Acute myocardial infarction (AMI; 5%), fractures (6%), and appendicitis (2%) were the health conditions associated with the highest number of claims. Over two-thirds of claims (70%) closed without payment to the claimant. Most claims that paid out did so through settlement (29%). Only 7% of claims were resolved by verdict, and 85% of those were in favor of the clinician. Over time, the average indemnity payments and expenses of litigation, adjusted for inflation, more than doubled, while both the total number of claims and number of paid claims decreased. CONCLUSIONS: Emergency physicians were the primary defendants in a relatively small proportion of ED claims. The disease processes associated with the highest numbers of claims included AMI, appendicitis, and fractures. The largest share of overall indemnity was attributed to errors in the diagnostic process. The financial liability of medical malpractice in the ED is substantial, yet the vast majority of claims resolve in favor of the clinician. Efforts to mitigate risk in the ED should include the diverse clinical specialties who work in this complex environment, with attention to those health conditions and potential errors with the highest risk.