Reducing the Risks of Pulmonary Embolism with Advanced Practice Providers

Pulmonary embolism (PE) accounts for 4% of medical malpractice claims among advanced practice providers insured by MagMutual. Pulmonary embolism can be life-threatening, with 10-30% of individuals dying within one month of diagnosis. PE affects around 900,000 people in the U.S. every year, and can be difficult to diagnose.¹

To help advanced practice providers reduce that number, MagMutual’s medical faculty and risk consultants have analyzed our claims data, determined the main causes of claims related to pulmonary embolism and developed strategies to improve patient outcomes. 

Top Risks

Top Strategies for Reduction

Based on these top risk drivers, implementing the following clinical and operational strategies can help you prevent unexpected outcomes and increase defensibility of a medical malpractice claim:

Clinical strategies

• Understand the risk factors for pulmonary embolism (e.g.., cancer, surgery, immobility, tobacco usage, hormonal medications, history of clots, family history of clotting disorder, etc.)
• In patients with tachycardia or hypoxemia, it is important to identify a satisfactory explanation for these symptoms. If no obvious cause is found, pulmonary embolism (PE) should be considered and possibly investigated further. If a patient presents with chest pain, dyspnea, cough or syncope, a lower extremity examination should be performed to evaluate for tenderness, warmth, erythema, edema, cyanosis, venous dilation, asymmetry or cords, as lower extremity deep vein thrombosis (DVT) is the most common cause of PE. While physical examination alone cannot rule out pulmonary embolism (PE), the presence of physical exam findings of deep vein thrombosis (DVT) should prompt clinicians to consider PE more likely. It is important to consider the risk factors for PE, such as immobility, surgery, trauma or a personal or family history of thrombosis. Appropriate diagnostic tests, such as a D-dimer, chest imaging, duplex ultrasound of the lower extremities or CT angiography of the chest, may be ordered based on the patient's presentation and risk factors.
• It is important to recognize that a significant PE with associated heart strain can mimic other diagnoses, such as non-ST-elevation myocardial infarction (NSTEMI) or pulmonary infiltrate. Therefore, clinicians should avoid anchoring to a particular diagnosis if it does not fit with the patient's clinical presentation. For instance, if a patient presents with hemodynamic instability and a small pulmonary infiltrate, clinicians should consider the possibility of PE rather than just treating with antibiotics. 

Operational strategies

• When evaluating a patient with chest pain, dyspnea or syncope, consider the use of a validated decision tool, such as the PERC score, in conjunction with a D-dimer, when indicated, for low to moderate-risk patients. This approach can help identify those who are at low risk for pulmonary embolism (PE) and avoid unnecessary testing. However, for high-risk patients with chest pain, dyspnea or syncope, computed tomography angiography (CTA) of the chest should be considered.
• Pulmonary embolism (PE) can present with atypical symptoms such as thoracic back pain and upper abdominal pain which may not immediately suggest a diagnosis of PE. It is important to maintain a high level of suspicion for PE in patients presenting with unexplained thoracic back pain and upper abdominal pain, particularly in those with additional risk factors, such as immobility, recent surgery or history of thrombosis.

Other Top Risks

Though pulmonary embolism accounts for a significant number of claims among advanced practice providers according to our data, we’ve identified several other drivers of loss based on claims frequency:

Risk Drivers by Top Cause

Risk Drivers by Frequency

Data Collection & Methodology

Data is based on MagMutual closed claims from 2011-2021 and corresponding exposure data. Clinical and non-clinical loss drivers are based on an in-depth review of each claim by a medical professional or clinical risk consultant. Risk reduction strategies are based on input from practicing physicians.

[1] https://emedicine.medscape.com/article/967822-overview#:~:text=United%20States%20statistics,than%202%20years%20of%20age.