Claims by specialty: MPL Association’s 2017-2021 national closed claim data

by Tanya Babitch, Assistant Vice President, Risk Management

When meeting with physicians, risk managers at Texas Medical Liability Trust (TMLT) are often asked to identify prevalent liability risks by specialty. The Medical Professional Liability (MPL) Association, a trade association of medical liability insurance companies, has been compiling data on medical claims since 1985 as part of its Data Sharing Project (DSP). Data sharing with the MPL Association allows insurers, including TMLT, to identify specialty-specific liability trends.

Since its inception, MPL Association members have shared more than 350,000 physician and dental professional claims with the DSP. (1) The DSP was created “to provide critical information needed to pinpoint areas of medical practice that have proven most vulnerable to MPL claims as well as support efforts seeking effective medical liability reform.” (2)

The following is a compilation of medical malpractice claim data from 2017 to 2021, submitted by member companies of the MPL Association. When submitting data, companies report data in a de-identified, codified format. Personally identifying information, such as names of claimants and insureds are not reported.

More than 32,000 closed claims and lawsuits were reported to the DSP between 2017 and 2021. During this period, the average cost to defend these claims was approximately $48,000 and nearly one-third of all claims (27.5%) resulted in an indemnity payment. The average indemnity payment to the claimant was $356,572. However, 65.9% of submitted closed claims were either dropped, withdrawn, or dismissed without indemnity payment to the claimant. (2)

The following report highlights the top five presenting medical conditions; chief medical factors; and outcomes per specialty. The paid-to-closed ratio is also provided. (3)

The chief medical factors categorize the general allegation or reason for claim against the medical provider. Please note, the MPL Association has implemented process changes within the past few years. For some specialties reported below, one of the top chief medical factors was in a no longer existing/reportable category. Those have been excluded from the information below.
The presenting medical condition is the disease, symptom, complaint, or reason for the patient’s visit; significant to the treatment provided at the time of the accident or incident.
The outcome is the medical condition that occurred after a medical encounter and led to the chief medical factor named in the claim. (4)

When reviewing this information, consider that some specialties may have a very low reported claim volume. This provides context and helps to explain information that seems counter-intuitive for a particular specialty.

For example, a medical outcome that seems unusual for a specialty may be due to a report of only one claim — and this claim could be an outlier. In addition, “top” presenting medical conditions or outcomes may reflect an incident that involved one patient, but multiple physicians or providers. Depending on the manner of the claim(s) submission — one versus multiple claims — this may make an issue appear more significant. Other outliers might include events such as a fall in the office that caused an injury, or other issues not directly related to the patient’s presenting condition. These outcomes might appear especially prominent if the specialty has few reported claims.

What follows is a snapshot summary of claims by specialty. This information is designed for use as a risk management tool to inform physicians about the nationwide risk trends for their specialty. We have included a 5-year span to capture pre-pandemic claims data.

The average indemnity for medical specialties is shown in the graph below, by lowest to highest average indemnity. Specialties with fewer than five paid claims during the 5-year timeframe are not included in the data. (5)

Allergy & Immunology*

Paid-to-close ratio: 26.1%

Top chief medical factors:

Diagnostic: Incomplete/Inadequate
Medication/IV Fluids: Adverse drug reaction
Medication/IV Fluids: Contraindication

Top presenting medical conditions:

Encounter for other special examination without complaint, suspected or reported diagnosis
Vasomotor and allergic rhinitis
Adverse effects, not elsewhere classified (NEC)
Allergy status to drugs, medicaments and biological substances
Encounter for procedures for purposes other than remedying health state

Top outcomes

Adverse effects, NEC
Other complications of surgical and medical care
Emotional distress only
Fracture at wrist and hand level
Hepatic failure, NEC

Anesthesiology

Paid-to-close ratio: 28.4%

Top chief medical factors:

Procedure: Incomplete/inadequate
Procedure: Failure to recognize complication
Medication/IV fluids: Adverse drug reaction

Top presenting medical conditions

Dorsalgia
Pain, NEC
Thoracic, thoracolumbar, and lumbrosacral intervertebral disc disorders
Other spondylopathies
Osteoarthritis of the knee

Top outcomes:

Cardiac arrest
Intraoperative and postprocedural complications and disorders of nervous system, NEC
Complications of procedures, NEC
Accidental puncture or laceration during a procedure, NEC
Other disorders of brain

Cardiology (Cardiovascular Disease)

Paid-to-close ratio: 26.6%

Top chief medical factors:

Procedure: Incomplete/inadequate
Diagnostic: Incomplete/inadequate
Procedure: Failure to recognize complication

Top presenting medical conditions

Chronic ischemic heart disease
Atrial fibrillation and flutter
Acute myocardial infarction
Pain in throat and chest
Other cardiac arrhythmias

Top outcomes

Cardiac arrest
Accidental puncture or laceration during a procedure, NEC
Acute myocardial infarction
Complications of procedures, NEC
Cerebral infarction

Cardiovascular and Thoracic Surgery

Paid-to-close ratio: 25.3%

Top chief medical factors:

Procedure: Incomplete/inadequate
Procedure: Failure to recognize complication
Diagnostic: Incomplete/inadequate

Top presenting medical conditions

Chronic ischemic heart disease
Aortic aneurysm and dissection
Nonrheumatic aortic valve disorders
Acute myocardial infarction
Arterial embolism and thrombosis

Top outcomes

Complications of procedures, NEC
Cardiac arrest
Intraoperative and postprocedural complications and disorders of circulatory system, NEC
Cerebral infarction
Complications of cardiac and vascular prosthetic devices, implants, and grafts

Critical and Intensive Care Medicine (combined specialties)*

Paid-to-close ratio: 20%

Top chief medical factors:

Diagnostic: Not performed when indicated
Procedure: Incomplete/Inadequate
Diagnostic: Incomplete/Inadequate

Top presenting medical conditions

Symptoms and signs specifically associated with systemic inflammation and infection
Complications of procedures, NEC
Peritonitis
Unspecified kidney failure
Hypotension

Top Outcomes

Cardiac arrest
Chronic kidney disease
Gangrene, NEC
Disorders of retroperitoneum
Hemiplegia and hemiparesis

Dermatology

Paid-to-close ratio: 22.3%

Top chief medical factors:

Procedure: Incomplete/inadequate
Diagnostic: Incomplete/inadequate
Procedure: Failure to recognize complication

Top presenting medical conditions

Other and unspecified malignant neoplasm of skin
Encounter for procedures for purposes other than remedying health state
Other disorders of skin and subcutaneous tissue, NEC
Malignant melanoma of skin
Follicular cysts of skin and subcutaneous tissue

Top outcomes

Other and unspecified malignant neoplasm of skin
Atrophic disorders of skin
Complications of procedures, NEC
Malignant melanoma of skin
Emotional distress only

Emergency Medicine

Paid-to-close ratio: 27.3%

Top chief medical factors:

Diagnostic: Incomplete/inadequate
Diagnostic: Not performed when indicated
Procedure: Incomplete/inadequate

Top presenting medical conditions

Abdominal and pelvic pain
Pain in throat and chest
Dorsalgia
Headache
Fever of other and unknown origin

Top outcomes

Cardiac arrest
Cerebral infarction
Paraplegia (paraparesis) and quadriplegia (quadriparesis)
Acute appendicitis
Other disorders of brain

Endocrinology, Diabetes, & Metabolism*

Paid-to-close ratio: 19.4%

Top chief medical factors:

Diagnostic: Incomplete/Inadequate
Diagnostic: Not performed when Indicated
Procedure: Incomplete/Inadequate

Top presenting medical conditions

Female infertility
Other hypothyroidism
Neoplasm of uncertain behavior of endocrine glands
Other disorders of adrenal gland
Type 2 diabetes mellitus

Top Outcomes

Emotional distress only
Cardiac arrest
Acquired absence of organs, NEC
Chronic kidney disease
Other anxiety disorders

Family Medicine

Paid-to-close ratio: 33.9%

Top chief medical factors:

Diagnostic: Incomplete/inadequate
Procedure: Incomplete/inadequate
Diagnostic: Unavailable/failure to diagnose

Top presenting medical conditions

Dorsalgia
Encounter for general examination without complaint, suspected or reported diagnosis
Abdominal and pelvic pain
Pain, NEC
Pain in throat and chest

Top outcomes

Cardiac arrest
Pulmonary embolism
Malignant neoplasm of bronchus and lung
Emotional distress only
Complications of procedures, NEC

Gastroenterology

Paid-to-close ratio: 23.7%

Top chief medical factors:

Procedure: Incomplete/inadequate
Diagnostic: Incomplete/inadequate
Procedure: Failure to recognize complication

Top presenting medical conditions

Encounter for screening of malignant neoplasms
Abdominal and pelvic pain
Other disease of digestive system
Other diseases of esophagus
Cholelithiasis

Top Outcomes

Accidental puncture or laceration during a procedure, NEC
Intraoperative and postprocedural complications and disorders of digestive system, NEC
Other diseases of intestine
Cardiac arrest
Injury of intra-abdominal organs

General Surgery & Bariatrics (combined specialties)

Paid-to-close ratio: 30.9%

Top chief medical factors:

Procedure: Incomplete/inadequate
Procedure: Failure to recognize complication
Diagnostic: Incomplete/inadequate

Top presenting medical conditions

Cholelithiasis
Cholecystitis
Overweight and obesity
Abdominal and pelvic pain
Diverticular disease of intestine

Top outcomes

Complications of procedures, NEC
Intraoperative and postprocedural complications and disorders of digestive system, NEC
Accidental puncture or laceration during a procedure, NEC
Injury of intra-abdominal organs
Other diseases of intestine

Hand Surgery

Paid-to-close ratio: 18.8%

Top chief medical factors:

Procedure: Incomplete/Inadequate
Procedure: Failure to recognize complication
Diagnostic: Incomplete/Inadequate

Top presenting medical conditions

Fracture at wrist and hand level
Fracture of forearm
Mononeuropathies of upper limb
Dislocation and sprain of joints and ligaments at wrist and hand level
Synovitis and tenosynovitis

Top Outcomes

Complications of procedures, NEC
Disorders of retroperitoneum
Complications of internal orthopedic prosthetic devices, implants and grafts
Intraoperative and postprocedural complications and disorders of nervous system
Other and unspecified soft tissue disorders, NEC

Hospital Medicine (Hospitalist)

Paid-to-close ratio: 21.7%

Top chief medical factors:

Diagnostic: Incomplete/inadequate
Procedure: Incomplete/inadequate
Procedure: Failure to recognize complication

Top presenting medical conditions

Pneumonia, unspecified organism
Abnormalities of breathing
Other sepsis
Pain in throat and chest
Type 2 diabetes mellitus

Top Outcomes

Cardiac arrest
Other sepsis
Pulmonary embolism
Symptoms and signs specifically associated with systemic inflammation and infection
Intracranial and intraspinal abscess and granuloma

Infectious Disease

Paid-to-close ratio: 16.2%

Top chief medical factors:

Diagnostic: Incomplete/inadequate
Procedure: Incomplete/inadequate
Medication/IV Fluids: Adverse drug reaction

Top presenting medical conditions

Osteomyelitis
Other sepsis
Complications of procedures, NEC
Complications of internal orthopedic prosthetic devices, implants, and grafts
Intracranial and intraspinal abscess and granuloma

Top outcomes

Acute kidney failure
Intracranial and intraspinal abscess and granuloma
Other sepsis
Cardiac arrest
Symptoms and signs specifically associated with systemic inflammation and infection

Internal Medicine

Paid-to-close ratio: 24.2 %

Top chief medical factors:

Diagnostic: Incomplete/inadequate
Diagnostic: Unavailable/failure to diagnose
Procedure: Incomplete/inadequate

Top presenting medical conditions

Abdominal and pelvic pain
Pain in throat and chest
Abnormalities of breathing
Dorsalgia
Pressure ulcer

Top outcomes

Cardiac arrest
Pulmonary embolism
Cerebral infarction
Pressure ulcer
Other sepsis

Nephrology

Paid-to-close ratio: 16.9%

Top chief medical factors:

Diagnostic: Incomplete/Inadequate
Procedure: Incomplete/Inadequate
Procedure: Failure to recognize complication

Top presenting medical conditions

Chronic kidney disease
Acute kidney failure
Other disorders of fluid, electrolyte and acid-base balance
Unspecified kidney failure
Abnormalities of breathing

Top outcomes

Cardiac arrest
Other sepsis
Symptoms and signs specifically associated with systemic inflammation and infection
Other demyelinating diseases of central nervous system
Shock, NEC

Neurological Surgery

Paid-to-close ratio: 26.5%

Top chief medical factors:

Procedure: Incomplete/Inadequate
Procedure: Failure to recognize complication
Diagnostic: Incomplete/Inadequate

Top presenting medical conditions

Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders
Other spondylopathies
Dorsalgia
Cervical disc disorders
Spondylosis

Top outcomes

Intraoperative and postprocedural complications and disorders of nervous system, NEC
Complications of procedures, NEC
Paraplegia (paraparesis) and quadriplegia (quadriparesis)
Complications of internal orthopedic prosthetic devices, implants, and grafts
Other paralytic syndromes

Neurology

Paid-to-close ratio: 31.5%

Top chief medical factors:

Diagnostic: Incomplete/inadequate
Procedure: Incomplete/inadequate
Diagnostic: Unavailable/failure to diagnose

Top presenting medical conditions

Cerebral infarction
Dorsalgia
Headache
horacic, thoracolumbar, and lumbosacral intervertebral disc disorders
Epilepsy and recurrent seizures

Top outcomes

Cerebral infarction
Emotional distress only
Paraplegia (paraparesis) and quadriplegia (quadriparesis)
Blindness and low vision
Other disorders of brain

Obstetrics & Gynecology (combined specialties)

Paid-to-close ratio: 33.2%

Top chief medical factors:

Procedure: Incomplete/inadequate
Diagnostic: Incomplete/inadequate
Procedure: Failure to recognize complication

Top presenting medical conditions

Leiomyoma of uterus
Pregnant state
Excessive, frequent, and irregular menstruation
Encounter for supervision of normal pregnancy
Other obstructed labor

Top outcomes

Birth injury to peripheral nervous system
Complications of procedures, NEC
Other disturbances of cerebral status of newborn
Emotional distress only
Accidental puncture or laceration during a procedure, NEC

Oncology & Hematology (combined specialties)

Paid-to-close ratio: 18.3 %

Top chief medical factors:

Procedure: Incomplete/Inadequate
Medication/IV fluids: Contraindication
Diagnostic: Incomplete/Inadequate

Top presenting medical conditions

Malignant neoplasm (without specification of site)
Malignant neoplasm of breast
Malignant neoplasm of bronchus and lung
Malignant neoplasm of colon
Other specified and unspecified types of non-Hodgkin lymphoma

Top outcomes

Unspecified parasitic disease
Cardiac arrest
econdary malignant neoplasm of other and unspecified sites
Respiratory failure, NEC
Poisoning by, adverse effect of, and underdosing of primarily systemic and hematological agents, NEC

Ophthalmology

Paid-to-close ratio: 20.2%

Top chief medical factors:

Procedure: Incomplete/inadequate
Procedure: Failure to recognize complication of treatment
Procedure: Unavailable/not performed when indicated

Top presenting medical conditions

Other cataract
Age-related cataract
Disorders of refraction and accommodation
Retinal detachments and breaks
Glaucoma

Top outcomes

Blindness and low vision
Poisoning by; adverse effect of; and underdosing of diuretics and other unspecified drugs, medicaments, and biological substances
Complications of procedures, NEC
Visual disturbances
Retinal detachments and breaks

Orthopedic Surgery

Paid-to-close ratio: 34.3%

Top chief medical factors:

Procedure: Incomplete/inadequate
Procedure: Failure to recognize complication
Procedure: Unavailable/not performed when indicated

Top presenting medical conditions

Other joint disorder, NEC
Osteoarthritis of knee
Osteoarthritis of hip
Fracture of lower leg, including ankle
Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders

Top outcomes

Other joint disorder, NEC
Complications of internal orthopedic prosthetic devices, implants, and grafts
Complications of procedures, NEC
Other acquired deformities of limbs
Intraoperative and postprocedural complications and disorders of nervous system, NEC

Otorhinolaryngology

Paid-to-close ratio: 32.5%

Top chief medical factors:

Procedure: Incomplete/inadequate
Procedure: Failure to recognize complication
Diagnostic: Incomplete/inadequate

Top presenting medical conditions

Chronic sinusitis
Encounter for procedures for purposes other than remedying health state
Other and unspecified disorders of nose and nasal sinuses
Chronic diseases of tonsils and adenoids
Diseases of vocal cords and larynx, not elsewhere classified

Top outcomes

Complications of procedures, NEC
Accidental puncture or laceration during a procedure, NEC
Intraoperative and postprocedural complication and disorders of nervous system, NEC
Diseases of vocal cords and larynx, NEC
Unhappy with results of plastic surgery

Pain Management

Paid-to-close ratio: 37.7%

Top chief medical factors:

Procedure: Incomplete/Inadequate
Medication/IV Fluids: Wrong Storage
Procedure: Failure to recognize complication

Top presenting medical conditions

Dorsalgia
Pain, NEC
Spondylosis
Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders
Other spondylopathies

Top outcomes

Intracranial and intraspinal abscess and granuloma
Emotional distress only
Complications of other internal prosthetic devices, implants, and grafts
Dorsalgia
Poisoning by; adverse effect of; and underdosing of narcotics and psychodysleptics

Pathology

Paid-to-close ratio: 30.4%

Top chief medical factors:

Diagnostic: Incomplete/Inadequate
Diagnostic: Unavailable/Failure to diagnose
Diagnostic: Wrong patient

Top presenting medical conditions

Unspecified lump in breast
Malignant neoplasm of breast
Abdominal and pelvic pain
Other disorders of skin and subcutaneous tissue, NEC
Other and unspecified malignant neoplasm of skin

Top outcomes

Emotional distress only
Malignant melanoma of skin
Malignant neoplasm of breast
Acquired absence of organs, NEC
Other anxiety disorders

Pediatrics

Paid-to-close ratio: 29.6%

Top chief medical factors:

Diagnostic: Incomplete/inadequate

Procedure: Incomplete/inadequate

Diagnostic: Not performed when indicated

Top presenting medical conditions

Encounter for general examination without complaint, suspected or reported diagnosis
Disorders of newborn related to short gestation and low birth weight, NEC
Nausea and vomiting
Encounter for procedures for purposes other than remedying health state
Neonatal jaundice from other and unspecified causes

Top outcomes

Cardiac arrest
Emotional distress only
Other disorders of brain
Intracranial laceration due to birth injury
Other disturbances of cerebral status of newborn

Physical Medicine & Rehabilitation

Paid-to-close ratio: 28.3%

Top chief medical factors:

Procedure: Incomplete/Inadequate
Diagnostic: Incomplete/Inadequate
Medication/IV fluids: Adverse drug reaction

Top presenting medical conditions

Dorsalgia
Pain, NEC
Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders
Other joint disorder, NEC
Encounter for other aftercare and medical care

Top outcomes

Poisoning by, adverse effect of and underdosing of narcotics and psychodysleptics
Cardiac arrest
Intraoperative and postprocedural complications and disorders of nervous system, NEC
Pressure ulcer
Dorsalgia

Plastic Surgery

Paid-to-close ratio: 26%

Top chief medical factors:

Procedure: Incomplete/inadequate
Procedure: Failure to recognize complication
Procedure: Wrong process/treatment/procedure

Top presenting medical conditions

Encounter for procedures for purposes other than remedying health state
Other disorders of breast
Hypertrophy of breast
Complications of other internal prosthetic devices, implants, and grafts
Malignant neoplasm of breast

Top outcomes

Complications of procedures, NEC
Unhappy with results of plastic surgery
Complications of other internal prosthetic devices, implants, and grafts
Disorders of retroperitoneum
Emotional distress only

Psychiatry

Paid-to-close ratio: 25.7%

Top chief medical factors:

Diagnostic: Incomplete/Inadequate
Medication/IV fluids: Adverse drug reaction
Procedure: Incomplete/Inadequate

Top presenting medical conditions

Bipolar disorder
Symptoms and signs involving emotional state
Major depressive disorder, single episode
Major depressive disorder, recurrent
Unspecified psychosis not due to a substance or known physiological condition

Top outcomes

Emotional distress only
Injury of unspecified body region
Other anxiety disorders
Symptoms and signs involving emotional state
Cardiac arrest

Pulmonary disease

Paid-to-close ratio: 16.4%

Top chief medical factors:

Diagnostic: Incomplete/Inadequate
Procedure: Incomplete/Inadequate
Procedure: Failure to recognize complication

Top presenting medical conditions

Respiratory failure, NEC
Abnormalities of breathing
Pneumonia, unspecified organism
Pulmonary embolism
Other disorders of brain

Top outcomes

Cardiac arrest
Other sepsis
Malignant neoplasm of bronchus and lung
Other disorders of brain
Pulmonary embolism

Radiation Therapy

Paid-to-close ratio: 19.2%

Top chief medical factors:

Procedure: Incomplete/Inadequate
Procedure: Failure to recognize complication
Procedure: Wrong process/Treatment/Procedure

Top presenting medical conditions

Malignant neoplasm of prostate
Other and unspecified malignant neoplasm of skin
Malignant neoplasm of brain
Malignant neoplasm of breast
Secondary malignant neoplasm of other and unspecified sites

Top outcomes

Complications of procedures, NEC
Radiation sickness, unspecified
Other anxiety disorders
Fissure and fistula of anal and rectal regions
Intraoperative and postprocedural complications and disorders of genitourinary system, NEC

Radiology

Paid-to-close ratio: 30.2%

Top chief medical factors:

Diagnostic: Incomplete/inadequate
Diagnostic: Unavailable/failure to diagnose
Procedure: Incomplete/inadequate

Top presenting medical conditions

Abdominal and pelvic pain
Dorsalgia
Encounter for screening for malignant neoplasms
Unspecified lump in breast
Other joint disorder, NEC

Top outcomes

Malignant neoplasm of breast
Malignant neoplasm of bronchus and lung
Complications of procedures, NEC
Cerebral infarction
Cardiac arrest

Urgent Care

Paid-to-close ratio: 30.8%

Top chief medical factors:

Diagnostic: Incomplete/Inadequate
Diagnostic: Not performed when indicated
Medication/IV fluids: Adverse drug reaction

Top presenting medical conditions

Cough
Abdominal and pelvic pain
Dislocation and sprain of joints and ligaments of thorax
Dorsalgia
Other fluke infections

Top outcomes

Cardiac arrest
Malignant neoplasm of bronchus and lung
Other inflammatory spondylopathies
Osteonecrosis
Scoliosis

Urology

Paid-to-close ratio: 26.4%

Top chief medical factors:

Procedure: Incomplete/Inadequate
Procedure: Failure to recognize complication
Diagnostic: Incomplete/Inadequate

Top presenting medical conditions

Malignant neoplasm of prostate
Calculus of kidney and ureter
Benign prostatic hyperplasia
Obstructive and reflux uropathy
Other disorders of urinary system

Top outcomes

Complications of procedures, NEC
Accidental puncture or laceration during a procedure, NEC
Malignant neoplasm of bladder
Malignant neoplasm of prostate
Intraoperative and postprocedural complications and disorders of genitourinary system, NEC

* Specialty had fewer than 50 claims reported to the DSP from 2017-2021.

Sources

Data Sharing Project. Medical Professional Liability Association. Available at https://www.mplassociation.org/data-sharing-project. Accessed August 30, 2023.
Data Sharing Project Dashboard. MPL Closed Claims Snapshot (2010-2021). Medical Professional Liability Association.
Data Sharing Project Dashboard. Data analysis by TMLT. Copyright 2021. MPL Association.
Data Sharing Project Dashboard. MPL Specialty Snapshot (2010-2021). Medical Professional Liability Association.

Tanya Babitch can be reached at tanya-babitch@tmlt.org.