Takeaway: Medication errors and patient falls present marked risks for oncology patients and practices. These types of adverse events, when they occur, are especially likely to result in malpractice claims with paid indemnities. Attention to systems factors such as practice policies and protocols, supported by staff training in adherence and implementation, can help protect patients from harm and practices from liability.
Background: A 2024 study of malpractice claims involving medical oncologists identified several patient safety themes, including adverse drug events, cognitive errors, and relational issues.
A New Analysis: The Doctors Company has examined a decade’s worth of its medical professional liability (MPL) claims involving medical oncologists, producing a new study that adds to knowledge around safe medical oncology care.1 The study authors found that systems factors and administrative issues were prevalent among claims that resulted in a paid indemnity. Common themes included insufficient staffing and lack of strong office policies and procedures.
Case Example: Selection and Management of Medication
The patient arrived for scheduled chemotherapy and was examined by an oncology nurse practitioner (NP). The patient had low white blood cells, low neutrophils, and a low neutrophil percentage. The NP did not confer with the oncologist and administered the chemotherapy cycle. Later in the day, an oncologist made rounds, saw the laboratory results, and felt the administration of chemotherapy was contraindicated. The patient was not told of the error but was warned of an increased risk of infection. Neulasta was ordered, but due to a system error, was not administered.
One week later, the patient was seen in the oncologist’s office with nausea and dehydration and was treated with IV fluids and antiemetics. No laboratory tests were obtained. A few days later, the patient went to the hospital with low critical levels of white blood cells. The diagnosis was neutropenic sepsis. The patient was admitted to the ICU, but had a complicated stay, including respiratory, cardiac, and gastric complications. The patient died a week later.
Clinical experts were critical of the decision to proceed with the chemotherapy in the presence of the abnormal laboratory results, and the failure to disclose this to the patient. Additionally, the patient’s follow-up in the office lacked attention to and treatment of the low white blood cell counts.
High-Severity Injuries in Oncology Claims
The Doctors Company’s study authors found that a total of 63% of the claimants experienced a high-severity injury: in fact, 43% of the patients had died. Medication-related allegations were the second-most common major allegation, with over half of studied claims resulting in a paid indemnity.
And all of the claims including allegations related to safety and security—these predominantly involved patient falls—resulted in a paid indemnity.
Clinical judgment may seem like an individual matter, but it can be strongly influenced by systems factors like over-packed schedules or frequent interruptions. Decisions like the one made by the NP in the case example—to proceed with chemotherapy in spite of some eye-catching lab results, and without consulting the oncologist—can sometimes be related to haste. Practice leaders can commit to introspection and scrutinize their own work environments for preventable sources of interruption, rush, distraction, and other detractors from clinicians’ cognitive bandwidth.
Tips for Malpractice Risk Mitigation: Focus on Protocols
Among the study’s claims that resulted in a paid indemnity, nearly 20% had a primary driver related to policies and procedures. This fact, in combination with the study’s other findings, charts a course toward improving patient safety while mitigating practice liability.
- Examination timing: For patients undergoing chemotherapy, consider the cadence of practitioner visits. Patients may inform practitioners that there are no problems with chemotherapy, when the reality is different. With this in mind, evaluating patients regularly during the chemotherapy cycle, as well as between the cycles, provides opportunities to observe how the patient is tolerating chemotherapy, address any significant side effects, detect complications early, and adjust dosages as necessary.
- Medication policies and procedures: Establish medication administration policies and procedures that designate who is responsible for administering or combining medications and where medication is mixed. Maintain a separate policy that specifically addresses staff training for medication administration. Consider using as your guide standards set by the American Society of Clinical Oncology–Oncology Nursing Society.
- Medication reconciliation: To decrease the risk of adverse medication interactions, ensure that medication reconciliation is completed upon every patient encounter.
- Fall prevention: Assessing fall risk is essential, especially in patients who are in a weakened, immunosuppressed state. Evaluate fall risk upon each patient visit. Appreciate when the risk of a patient fall is high:
- When transferring from a wheelchair.
- After an injection or blood draw.
- While waiting unattended on an exam table.
Build fall prevention into your office work processes, including fall risk communication during handoffs. Assess your office furniture and equipment for its sturdiness. Ensure that the examination and waiting rooms do not contain unneeded clutter.
Errors in medication management and patient falls are both areas of noted risk for oncology practices, but these risks can be mitigated through systems improvements such as establishing clear practice protocols and procedures, followed by regular staff training to strengthen adherence.
This discussion of practice risks in medical oncology is based on Learning From Medical Oncology Malpractice Claims, published by The Doctors Company.
Reference
1 CRICO-Candello. Copyrighted by and used with permission of Candello a division of The Risk Management Foundation of the Harvard Medical Institutions Incorporated, all rights reserved. As a member of the Candello community, The Doctors Company participates in its national medical malpractice data collaborative.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.