Medico-legal risk: What neurologists need to know

As of the end of 2021, 1,341 CMPA members were neurologists (Type of Work 56). In the recent 5 years (2017 – 2021)¹, 17.8% of neurologists were named in one new medico-legal case (legal action, College or hospital complaint), and another 5.6% were named in 2 or more new cases.

Annually, 5.9% of neurologists were named in one new medico-legal case, and an additional 0.7% were named in two or more new cases on average across this 5-year period.

The graphs below compare the 10-year trends in neurologists’ medico-legal experiences with those of the general CMPA membership.

What are the relative risks of a medico-legal case for neurologists?

In the past 10 years, there was not significant difference of College complaint² rates between neurologists and the general CMPA membership, although rates of neurologists’ College matters fluctuated widely between 2016 and 2020.

In the past 10 years, the risk of civil legal actions for neurologists were similar to that of all CMPA members.

The following sections describe the findings based on the 511 civil legal cases, College, and hospital matters involving neurologists with peer expert criticism that were closed by the CMPA between 2012 and 2021.

What are the most common patient complaints and peer expert criticisms?³ (n=511)

Complaints are a reflection of the patient’s perception that a problem occurred during care. They are not always supported by peer expert opinion. Peer experts may not be critical of the care provided, or may have criticisms that are not part of the patient allegation. These complaints might not result in a negative finding by a College or court.

What are the most frequent patient presenting conditions? (n=511)

Frequencies of the presenting conditions among medico-legal cases are likely representative of neurologists’ practice patterns and do not necessarily reflect high-risk conditions.

In the 511 cases, 95 patients experienced a misdiagnosis or delayed diagnosis, often resulting in severe patient harm. For example:

• Failure to question the initial diagnosis of cerebral vascular accident due to inconclusive imaging results contributed to a delay in diagnosis of a brain tumor.
• Failure to appreciate the patient’s diminished Glasgow Coma Scale (GCS) contributed to a failure to perform imaging, which would have confirmed a subdural hematoma.
• A deficient hospital test follow-up system and a physician’s failure to follow-up on a cerebral angiogram contributed to a missed cerebral aneurysm.

What are the top factors associated with severe patient harm⁴ in medico-legal cases? (n=511)

Risk reduction reminders

The following risk management considerations have been identified for neurologists.

• Gather an appropriate medical history from the patient, including comorbidities and current medications, and conduct a focused physical examination including vital signs.
• Consider whether additional diagnostic tests or consultations are necessary to establish or confirm the diagnosis. Incorporate clinical pathways, clinical practice guidelines, or decision tools as appropriate.
• Document discussions, treatment plans, and other clinical issues in patients’ medical records. Clear documentation can improve continuity of care as it provides the rationale for the physician’s clinical decision-making and communicates what took place during the patient encounter to other providers.
• Thoroughly assess the patient’s fitness for discharge. Inform the patient about symptoms and signs that should alert them to seek further medical attention, and when and whom to consult in the event of complications.
• Appropriately advocate on behalf of patients to solve issues that arise when limited resources pose an impediment to safe patient care, and document any steps you have taken to attempt to resolve the resource issue within a reasonable timeframe.

Now that you know your risk…

Mitigate your medico-legal risk with CMPA Learning resources.

• CMPA workshop: Advanced Diagnostic Reasoning
• CMPA workshop: Test results follow-up
• eLearning activity: Informed consent
• eLearning activity: Informed discharge
• eLearning activity: Documentation

Questions?

Please contact [email protected]

Notes

1. 1. 
   It takes an average of 2-3 years for a patient safety incident to progress into a medico-legal case. As a result, newly opened cases may reflect incidents that occurred in previous years.
2. 2. 
   Physicians voluntarily report College matters to the CMPA. Therefore, these cases do not represent a complete picture of all such cases in Canada.
3. 3. 
   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.
4. 4. 
   Severe patient harm includes death, catastrophic injuries, and major disabilities. Healthcare-related harm could arise from risk associated with an investigation, medication, or treatment. It could also result from failure in the process of patient care.
5. 5. 
   Patient factors include any characteristics or medical conditions that apply to the patient at the time of the medical encounter, or any events that occur during the medical encounter.
6. 6. 
   Based on peer expert criticism.