Primary care by family physicians and general practitioners

Know your risk: Medico-legal data by clinical specialty

4 minutes

Published: October 2022

The Canadian Medical Protective Association (CMPA) represents over 105,000 physicians and draws experience from its database of over 500,000 medico-legal cases. These cases include civil legal actions, regulatory authority (Colleges), and hospital matters.

As of the end of 2021, 37,083 CMPA members were family medicine and general practice physicians (Type of Work 35, 73, 78 and 79). In addition to primary care, some of these physicians (Type of Work 73, 78 and 79) provide specialized care including surgery, anesthesia, obstetrics, and shifts in the emergency department.

Between 2016 and 2020, the CMPA closed 6,175 medico-legal cases involving family physicians providing primary care, i.e. non-specialized services. This report describes findings based on these medico-legal cases (civil legal actions, College
complaints, and hospital matters).

What are the most common patient complaints? (n=6,175)1

Deficient assessment (37%), Inadequate consent process (30%), Diagnostic error (25%), Injury associated with healthcare procedure (21%), Inadequate monitoring or follow-up (19%), Communication breakdown with patient (17%)

  •  Deficient assessment (37%)
  •  Inadequate consent process (30%)
  •  Diagnostic error (25%)
  •  Injury associated with healthcare procedure (21%)
  •  Inadequate monitoring or follow-up (19%)
  •  Communication breakdown with patient (17%)

Complaints are a reflection of the patient’s perception that a problem occurred during care. These complaints are not always supported by peer expert opinion. Peer experts2 may not be critical of the care provided, or may have criticisms that are not part of the patient complaint.

Diagnostic error is a major issue for primary care physicians. The remaining sections of this report focus on the 1,260 cases in which diagnostic error was identified by the peer experts.

What are the most frequent misdiagnoses? (n=1,260)

Patient conditionMisdiagnosis
  • GI cancer
  • Intestinal disorders
  • Nutritional anaemias
  • Other digestive system disorders
  • Back disorder
  • Injuries to lumbosacral areas
  • Soft tissue disorders
  • Other back disorders
  • Breast cancer
  • Benign neoplasm
  • Breast disorders
  • Ischemic heart disease
  • Digestive system disorders
  • Lower respiratory infections
  • Back, nerve or joint disorders
  • Secondary or ill-defined cancer
  • Influenza and pneumonia
  • Intestinal disorders
A patient’s true condition can be mistaken for a variety of other conditions. For each condition, no single wrong diagnosis is predominant.

What are the top factors associated with severe patient harm? (n=1,260)3

Patient factors

With underlying diagnosis of:

  • Ischemic heart disease
  • Cancer of female genital organs
  • Arterial vascular disease, e.g. atherosclerosis
  • Carcinoma in situ
  • Comorbid condition of secondary cancer

Provider factors4

  • Failure to perform diagnostic test or intervention
  • Failure to refer, admit or transfer patient
  • Inadequate monitoring or follow-up

System factors4

  • Inadequate office policy or procedure

Team factors4

  • Poor coordination of care
  • Inadequate handover
  • Communication breakdown with other healthcare professionals

Risk reduction reminders

The following risk management considerations have been identified for reducing diagnostic errors in primary care:

  • Review all key elements of the patient’s medical record including earlier entries and referral notes. Pay attention to abnormal vital signs or physical findings.
  • Actively consider what information supports the favoured diagnosis and what information does not fit, and thus minimize cognitive biases.
  • Optimize office procedures for
    • flagging abnormal results;
    • generating a communication task to inform the patient of results;
    • outlining the timeframe to communicate with patients who require urgent follow-up; and
    • confirming that patients have received messages and booked appropriate follow-up.
  • Take a structured approach (e.g. SBAR, I-PASS) to communicating key information from the patient profile (e.g. medications, allergies, and patient wishes including advance directives and special exemptions) at patient handover and at every transition of patient care. Ensure important information is flagged during patient handover.
  • Clearly define the roles and responsibilities of each team member to optimize care.

Limitations

CMPA medico-legal cases represent a small proportion of patient safety incidents overall. Many factors influence a person’s decision to pursue a case or file a complaint, and these factors vary greatly by context. Thus, while medico-legal cases can be a rich source for important themes, they cannot be considered representative of patient safety incidents overall.

Now that you know your risk…

Mitigate your medico-legal risk with CMPA Learning resources.

Questions?

Please contact [email protected]




Notes

  1. There may be more than one complaint per case.
  2. Peer experts refer to physicians who interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided. They are typically of similar training and experience as the physicians whose care they are reviewing.
  3. Severe patient harm refers to harm that results in patient death or severe outcome.
  4. Based on peer expert opinions.