N=294 diagnostic-related events in the MD office closed 2020-2024. of diagnostic-related events involving office-based care were closed with indemnity payment. 53% Indemnity Paid More than half (53%) of the events were closed with an indemnity payment (via settlement or trial) with an average indemnity of $661,000. This is more than twice the average indemnity paid on claims that were not diagnostic- related ($323,000). ( 8 ) | HIDDEN IN PLAIN SIGHT | Exposing the Drivers of Diagnostic Error A DOSE OF INSIGHT ® Coverys | N=552 events with a diagnosis-related case type in the office-based setting closed 2020-2024. Diagnosis- Related Events in Office-Based Settings Non- Diagnosis- Related Events in Office-Based Settings $661K $323K AVERAGE INDEMNITY PAID CASE SUMMARIES Failure to document – A primary care provider recommended a patient with an abnormal EKG and chest pain to go directly to the ED but did not document the recommendation. The patient did not go to the ED and died of a MI the next day. Failure to follow up on test results – A patient with advanced kidney disease died unexpectedly four days after a nephrology visit. An abnormal lab result was not communicated or acted upon prior to the patient’s death. Failure to ensure follow-up after declined imaging – A patient presented with right breast inflammation. An ultrasound was recommended but declined. There was no recommendation for a follow-up visit for reevaluation. The delay in follow-up resulted in the patient’s death from breast cancer. Failure to investigate persistent symptoms – A patient reported ongoing abdominal and back pain and changes in stool appearance at two separate internal medicine visits. The NP dismissed the abdominal/stool complaints and only treated the back pain. A year later, the patient was diagnosed with colon cancer. Failure to communicate incidental findings – An incidental finding of a lung mass on a chest X-ray was not conveyed to the patient or the primary care provider thus no follow up care was in place. The patient was subsequently diagnosed with stage 3B lung cancer. N=890 events excluding a diagnosis-related case type in the office-based setting closed 2020-2024 N=552 events with a diagnosis-related case type in the office-based setting closed 2020-2024. Diagnosis- Related Events in Office-Based Settings Non- Diagnosis- Related Events in Office-Based Settings $661K $323K VISUAL #8 - AVERAGE INDEMNITY PAID