Shelley Rizzo, MSN, CPHRM, Senior Patient Safety Risk Manager, The Doctors Company

Because a cerebrovascular accident (CVA) can happen in any healthcare setting, it is imperative that all healthcare providers and staff have the ability to spot the signs and symptoms promptly. Timely diagnosis and treatment can minimize injury severity and improve patient outcomes.

In a review of claims closed by The Doctors Company from 2009 through 2020, we identified 395 claims with a final diagnosis of acute CVA. Our review addresses the following: case types, factors that contributed to patient harm, patient injuries, patient injury severity, locations where the patient allegedly suffered harm, and patient comorbidities that affected the outcome of care.

The information obtained from analyzing these claims provides useful statistics and insightful risk reduction strategies that can help clinicians improve patient safety. The two case summaries presented here also provide valuable information about the types of patient safety and risk management issues that contribute to CVA claims.

Most Common Case Types Related to CVA

The most common types of CVA cases included claims related to diagnosis (failure, delay, or wrong) (42 percent), management of treatment plan (20 percent), and medication management (14 percent).

Diagnosis-Related Claims

Diagnosis (failure, delay, or wrong) was the most common allegation in claims arising from CVAs. Factors related to diagnosis of CVA that contributed to patient injuries included inadequate patient assessments (70 percent), failure or delay in obtaining a consult or referral (28 percent), and lack of communication among providers (23 percent).

Patient assessment issues included a failure to appreciate and reconcile relevant signs, symptoms, and test results and a failure or delay in ordering diagnostic tests. Other factors related to patient assessments were misinterpretation of diagnostic studies and overreliance on negative findings for patients with ongoing symptoms.

One additional factor in diagnosis-related claims was failure or delay in obtaining a consult or referral. In some cases, we found that the patient was not referred to a neurologist because the diagnosing clinician did not feel that the symptoms justified additional evaluation.

Communication among clinicians regarding patients’ conditions was a factor in 23 percent of diagnosis-related claims. In some cases, important information was not given to the clinicians providing care to the patient. In other cases, information was lost during transitions of patient care.

Consider the following case studies involving the diagnosis and treatment of CVA:

Case One: Patient Assessment Issues With Failure to Establish a Differential Diagnosis

A 57-year-old female with a diagnosis of morbid obesity presented to the hospital for reversal of a jejunal bypass and conversion to gastric bypass. The patient had undergone the jejunal bypass approximately 15 years earlier and suffered from daily diarrhea. The insured general surgeon had performed fewer than six other operations of this type.

The patient was taken to the operating room and had no complications noted during the surgery. Postoperatively, she was transferred to the postanesthesia care unit and did well. She was then transferred to the surgical floor.

On the second postoperative day, the family told the nurses that the patient was confused and nonresponsive. The nurses attributed the patient’s condition to the pain medication and did not call the doctor. On the third postoperative day, the patient had a high temperature and was hypotensive, nonresponsive, and draining foul-smelling brown fluid from the wound site.

The general surgeon examined the patient, suspected a leak, and transferred her to the ICU, but the patient was not taken to the operating room until approximately 12 hours later. The medical record contained no explanation for the delay.

Once in the OR, the general surgeon repaired a small leak at the anastomosis. Copious foul-smelling fluid in the abdomen was irrigated with antibiotic solution and drains were placed. The patient was then transferred to the ICU and placed on a ventilator. The nurses noted that the patient was not moving her left side. A CT of the brain revealed a cerebral infarct.

The patient was transferred to a larger hospital for a neurosurgery consult but expired two days later. The cause of death was determined to be multiple brain infarcts. The plaintiff’s experts alleged that the brain infarcts were related to sepsis from the leak and that the leak should have been recognized and repaired sooner.

Case Two: Failure to Diagnose and Delayed Treatment of CVA

A 76-year-old male presented to the emergency department of the hospital. He stated that he had fallen and complained of pain in the left wrist. A small abrasion was noted at the left lateral eyebrow. The patient said he had lost consciousness for a few seconds.

He was diagnosed with new onset of atrial fibrillation with syncope, comminuted Colles’ fracture, and facial abrasion. The patient was admitted with an internal medicine physician as the attending. A cardiology consult for atrial fibrillation was obtained. The cardiologist recommended starting Lovenox and Coumadin. The patient was recovering well and was admitted to the hospital.

At 9:00 PM, the nurse noted that the patient was staring but responding appropriately. At 9:45 PM, the nurse noted the phone rang and the patient attempted to answer it using the urinal. At 10:35 PM, the nurse noted the patient was not oriented to name, place, or time.

The nurse notified the attending physician, who ordered “give Haldol 2 mg IM every four hours for agitation as necessary.” At 11:37 PM, the patient’s family notified the nurse that the patient was acting strangely. The nurse noted that his pupils were equal and reactive to light. At 12:10 AM, the patient was noted to be sleeping. At 1:00 AM, the patient was found on his knees beside the bed. He complained of a slight headache, and a question was raised about whether he had hit his head. The nurse called the attending physician, who ordered “non-stat CT of head in the morning, get blood urea nitrogen and creatine, and may restrain the patient.” During the rest of the night, the patient was noted to be sleeping.

At 8:00 AM, the shift changed, and a new nurse noted the patient was unresponsive, with pupils that were unequal and sluggish. The nurse did not call the physician because she thought the physician would be in shortly for rounds. The physician arrived approximately 45 minutes later.

The physician ordered a stat CT of the brain, which was read as left cerebral hemorrhage. The patient was made do-not-resuscitate status and expired that afternoon.

The plaintiff alleged that delayed diagnosis and delayed treatment of the CVA led to the patient’s death. Experts opined that CVA should have been part of the differential diagnosis for this patient after suffering a fall, receiving anticoagulants, exhibiting confusion, and complaining of a headache. The plaintiff’s experts felt that the first nurse should have gone up the chain of command to get help for the patient since he was clearly having decreased mentation. Experts also felt that when the patient was found unresponsive, the second nurse should have called the physician immediately rather than waiting for the physician to make rounds on the patient.

Lessons Learned from These Diagnosis-Related Case Studies

Both case studies examined involved the diagnosis and treatment of CVA in which care was found to be lacking.

Because CVA is relatively common, it should be included in the differential diagnosis for any patient who complains of or exhibits typical signs and symptoms: headache, confusion, numbness or paralysis of one side of the body, blurred vision, or difficulty with speech.

It is important that staff also recognize the common symptoms of CVA and acknowledge concerns raised by family members. It is imperative that nurses and other caregivers relay changes in a patient’s condition to the responsible clinician. Communication and teamwork may result in a faster diagnosis, earlier treatment, and a better prognosis for the patient.

Improper Management of Treatment Plan

The second most common allegation in CVA claims was improper management of treatment. This included selection of treatment and failure to order medications (such as t-PA and other anticoagulants). In some cases, patients presented with symptoms of headache, weakness, or visual disturbances. Other cases involved patients who were scheduled for cardiac procedures and experienced thrombosis when not anticoagulated.

When treatment was delayed, clinicians were sometimes criticized for failing to recognize relevant signs and symptoms, or radiologists were found to have incorrectly interpreted imaging studies.

Improper Medication Management

Cases involving medication management were the third most common allegation in CVA claims. Most often, this included allegations of failure to order medications (such as anticoagulants). In some cases, the most appropriate medication was not used. Other allegations included inadequate documentation of medication use and failure to educate patients on the risks of medications.

Services Responsible for Patient Care

We found the following in a review of the top clinical services responsible for care when the patient suffered harm from a CVA:

• Emergency Medicine (17%)
• Internal Medicine (10%)
• Hospitalist (10%)
• Neurology (9%)
• Cardiology (8%)
• Radiology (7%)
• Family Medicine (7%)

Setting

Patients were admitted to the hospital in half of the cases involving allegations related to CVA. In 26 percent of CVA claims, the patient was evaluated and treated in an ambulatory setting (including the clinician’s office). In 24 percent of CVA claims, the patient presented to an emergency department for evaluation.

• Inpatient (50%)
• Outpatient/Ambulatory (26%)
• Emergency Department (24%)

Injury Severity

The nine levels of injury severity as defined by the National Association of Insurance Commissioners on its Injury Severity Scale are listed below with the percentages of patients in our study diagnosed with CVA. No claims had an injury in the low-severity range, 21 percent were in the medium-severity category, and 79 percent were in the high-severity category.

Low-severity injuries

1. Emotional only (0%)
2. Temporary insignificant (0%)

Medium-severity injuries

1. Temporary minor (1%)
2. Temporary major (2%)
3. Permanent minor (18%)

High-severity injuries

1. Permanent significant (24%)
2. Permanent major (18%)
3. Permanent grave (3%)
4. Death (34%)

Where Injuries Occurred

We found that patients suffered the effects of CVAs prior to presenting for care, after presenting to clinicians’ offices and emergency departments with complaints, and during hospitalization. Here are where the injuries occurred:

• Patient’s room (33%)
• Emergency department (23%)
• Clinician office (18%)
• Intensive care unit (7%)
• Radiology/imaging (4%)
• Ambulatory/day surgery (4%)
• Hospital operating room (4%)
• Special procedure (2%)
• Cardiac catheterization laboratory (2%)
• Other locations: <1% each

Top Comorbidities Contributing to Claims

Although patients presented with comorbidities, only those comorbidities regarded by physician reviewers as having contributed to the event and/or injury or illness were included in the study.

• Hypertension (26%)
• Cardiovascular disease (17%)
• Diabetes (11%)
• Obesity (7%)
• Smoking (6%)
• Cerebrovascular disease (4%)

Factors Contributing to Patient Injury

We focused on the top five factors that contributed to harm in cases in which patients were diagnosed with CVA. The information includes factor subcategories to provide additional clarity.

Note that patients may experience more than one factor, so the totals are sometimes greater than 100 percent.

• Patient assessment issues (44%)
  • Failure to appreciate and reconcile relevant signs, symptoms, and test results (15%)
  • Failure or delay in ordering diagnostic tests (14%)
  • Failure to establish a differential diagnosis (12%)
  • Misinterpretation of diagnostic studies (x-rays and other radiographic studies) (8%)
  • Inadequate history and physical (7%)
• Communication among providers (25%)
  • Regarding patient’s condition (20%)
  • Failure to read medical record (3%)
  • Information lost during transitions in care (2%)
• Selection and management of therapy (23%)
  • Failure to order medication (9%)
  • Selection and management of medication, other (5%)
  • Selection of medical treatment (4%)
  • Selection of invasive procedure (4%)
• Communication between patient/family and providers (18%)
  • Communication between patient/family and providers, other (4%)
  • Poor rapport (includes unsympathetic response to patient) (4%)
  • Communication between patient/family and providers regarding expectations (3%)
• Failure or delay in obtaining a consult or referral (18%)

Risk Mitigation Strategies

Consider the following patient safety strategies:

• Ensure that, regardless of the setting, all members of the healthcare team are able to recognize and respond to symptoms of a CVA. This is important because CVAs can occur at any time and in any location—including prior to presenting for care, after presenting to a clinician’s office or emergency department, and during hospitalization. Triage protocol training is essential to facilitate further evaluation and treatment in a timely manner.
• Conduct thorough assessments, including a comprehensive history and physical exam, and consider all differential diagnoses.
• Obtain timely consultations and referrals to specialists for concerning symptoms or challenges in diagnosis.
• Consider and order the most appropriate medication promptly, and document the rationale. (Many legal claims result from a failure to offer tPA.) During informed consent discussions, educate the patient and family members on the risks of the medication.
• Document the patient record clearly and concisely. This information is vital to verify the progression of symptoms and corroborating a timeline of the care and interventions provided (such as diagnostic studies and medication management).
• Offer education programs to all patient care staff to enhance their assessment, communication, and decision-making skills as part of the patient care team.
• Encourage excellent handoff communication to ensure that critical patient information is accurately passed to team members in support of continuity of care, especially during transitions in care.
• Follow state laws for the type and extent of physician supervision or collaboration required for all team members, including any advanced practice clinicians and doctors in training.
• Promote team building activities and a culture of respect among all staff and clinicians. Implement the Agency for Healthcare Research and Quality’s TeamSTEPPS® program. Use TeamSTEPPS skills to encourage mutual support, promote conflict resolution strategies, and enhance team communication with structured handoffs that minimize errors and prevent delays in treatment.
• Encourage patients and family members to learn about and share information on the warning signs of a stroke. See the American Stroke Association’s F.A.S.T Warning Signs.