By Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)
In the early months of the COVID-19 epidemic, abnormal clotting was found in COVID-19 patients. As Bin Cao, MD, who is with the National Clinical Research Center for Respiratory Diseases in Beijing, described wide-spread clots in COVID-19 patients in a March 19, 2020 webinar cosponsored by the Chinese Cardiovascular Association and the American College of Cardiology – he found “clots in the small vessels of all organs, not only the lungs but also including the heart, the liver, and the kidney.”
More recently, in a study by Harvard Medical School, investigators at Massachusetts General Hospital similarly found clotting in patients with COVID-19:
- Patients with high levels of the blood clotting protein factor V were found to be at an elevated risk for serious injury from blood clots such as deep vein thrombosis or pulmonary embolism.
- Patients with low levels of factor V were found to be at an increased risk for death from “a form of coagulopathy that resembles disseminated intravascular coagulation (DIC)—a devastating, often fatal abnormality in which blood clots form in small vessels throughout the body, leading to exhaustion of clotting factors and proteins that control coagulation.”
Because abnormal clotting has been found in COVID-19 patients, it’s even more important to accurately diagnose thrombosis in patients admitted to hospital.
Vascular events have been found to account for almost a third of malpractice claims. In research funded by the Society to Improve Diagnosis in Medicine, David Newman-Toker, et al. (John Hopkins University and CRICO Strategies) in Serious Misdiagnosis-Related Harms in Malpractice Claims, analyzed more than 55,000 malpractice claims and found that 74.1% of diagnostic error malpractice claims were attributable to three conditions: cancer (37.8%), vascular events (22.8%) and infection (13.5%).
Such misdiagnosis of thrombosis is particularly critical in maternal patients. Even though maternal injury claims account for less than a fifth of the obstetric claims, research by The Doctors Company found that 38% of the maternal injury claims resulted in settlements or judgments, a percentage much greater than other average paid claims.
The Agency for Healthcare Research and Quality identified the problems associated with thrombosis assessment, saying in its report, Preventing Hospital-Associated Venous Thromboembolism, “there is no consensus regarding the preferred VTE risk assessment tool … There is no consensus on the answer to the fundamental question, ‘How can hospitals assess VTE risk, then ensure adequate prophylaxis for patients who need it, while minimizing excess prophylaxis, in a practical, efficient way?’”
Moreover, an assessment of thrombosis risk is currently very costly regarding maternal patients. According to Crico Strategies, “Annual Benchmarking Report: Malpractice Risks in Obstetric,” the average payment in obstetric malpractice cases is more than twice that of other clinical areas and exceeds $900,000.
As well, an assessment of thrombosis risk is currently unreliable for maternal patients. In their review of maternal deaths, S.M. Nelson and I.A. Greer in Management of Venous Thrombosis in Pregnancy, conclude that “In nonpregnant individuals, DVT is confirmed in about 20–30 percent of suspected cases. In pregnancy, however, leg symptoms, chest pain and dyspnoea from non-thrombotic causes are common; consequently, the accuracy of clinical diagnosis falls to 8 percent for DVT and to less than 5 percent for PE.”