CMPA research: Improving patient safety by reducing delays in sepsis diagnosis

OTTAWA, February 10, 2023—The Canadian Medical Protective Association (CMPA) is pleased to share key findings learned from its peer-reviewed study, Diagnostic delays in sepsis: Lessons learned from a retrospective study of Canadian medico-legal claims. The CMPA conducts data-driven research to increase patient safety, while reducing the medico-legal risks of member physicians.

CMPA researchers examined 163 medico-legal cases closed between 2011-2020 that had documented peer expert criticism of a delayed diagnosis related to sepsis or relevant infections, including endocarditis, C. difficile, and S. aureus.

The CMPA’s retrospective study sought to identify the potential warning signs for patients at risk of developing severe sepsis, identify what patient characteristics and elements of healthcare contributed to delays in the diagnosis of sepsis, and identify opportunities for improvement.

Sepsis explained

Sepsis is the body's extreme response to a serious infection that can cause organs to function poorly or abnormally. It is a potentially life-threatening condition, which continues to be a challenging diagnosis for physicians. Although rapid treatment improves outcomes for patients presenting with sepsis, early detection can be difficult, especially in otherwise healthy adults.

In 2017, there were an estimated 11 million sepsis-related deaths worldwide and the mortality rate has decreased very little in recent decades, despite advances in sepsis management.

CMPA’s key findings

Healthcare provider factors were identified in 160 cases of the 163 cases. These factors include inadequate monitoring or follow-up, failure to perform a test/intervention or administer medication, and not sufficiently assessing patient conditions.

“In 129 cases, which is over 80% of the cases, it was determined that healthcare providers hadn't sufficiently assessed patients' conditions,” said Jacqueline Fortier, Manager of the Evidence Synthesis Unit at the CMPA. “Key considerations, such as thinking broadly about other causes of post-operative pain or taking the time to reassess a high-risk patient before discharging them from the emergency department, could contribute to an earlier sepsis diagnosis.”

Additional findings include:

  • In the 163 cases included in the study, 49% of patients made multiple visits to outpatient care before the symptoms had progressed to sepsis, and almost 40% of patients required intensive care unit attention during their hospitalization.
  • In 30% of the 163 cases, patients who brought forward a medico-legal action had experienced severe harm, such as limb amputation due to gangrene or brain damage.
  • Deficient assessments, such as failing to consider sepsis or not reassessing the patient prior to discharge, contributed to just over 80% of the 163 cases.
  • In nearly 24% of 88 cases where team factors were identified, communication breakdowns between healthcare providers occurred.

Opportunities for improving patient safety

The top contributing factors attributed to healthcare teams were inadequate documentation and communication breakdowns, either between healthcare professionals or between physicians and patients/caregivers. “How physicians communicate—with each other, with patients, and their families—plays a significant role in delayed diagnoses,” said Dr. Gary Garber, Director, Safe Medical Care Research and senior author of the study. “Critical care physicians might consider how best to coordinate the care of patients at increased risk of sepsis with other team members to help improve outcomes.”

Sepsis continues to be a challenging diagnosis for clinicians. Multiple visits to outpatient care may be an early warning sign requiring vigilance in the patient assessment. Being mindful of certain factors, such as deficient assessments and inadequate monitoring, can potentially improve patient outcomes. Medico-legal data can help to identify clues about the sources of delayed diagnoses. Outcomes for patients with sepsis can be improved through the early recognition of sepsis and appropriate management, which may include communicating early with critical care teams.


CMPA peer-reviewed research is conducted using CMPA data, the largest collection of medico-legal data in the world. CMPA studies are published in medical and science journals and inform collaborative research initiatives.

Review the published research, available at Critical Care Explorations.

For more information, or to arrange an interview: [email protected]

About the CMPA

The CMPA empowers better healthcare by delivering efficient, high-quality physician-to-physician advice and assistance in medico-legal matters. Importantly, the CMPA provides appropriate compensation, on behalf of our members, to patients injured by negligent medical care (fault in Québec). Our peer-reviewed research results in evidence-based products and services focused on enhancing patient safety and reducing patient harm and healthcare costs.

As Canada’s largest physician organization and with the support of our nearly 109,000 physician members, the CMPA collaborates, advocates, and effects positive change on important healthcare and medico-legal issues. The Association is governed by an elected Council of physicians.