Medico-legal Risk in the Emergency Department

Medico-legal Risk in the Emergency Department

Authors: Cortel-LeBlanc MA, Lemay K, Chhabra S, Yang Q, Ji J, Woods S, El Sherif R, Garber G
Journal: CJEM, November 2025 (Canada; CMPA closed cases 2018–2022)

Conclusions:

  • Medico-legal exposure is common and often unfavorable: >50% of ED-related complaints ended with an unfavorable outcome for the physician.

  • Top risk drivers are “human factors” we can target: clinical decision-making (64%), situational awareness (44%), and documentation deficits (42%) were the most frequent contributors in criticized cases.

  • High-risk chief complaint categories: injuries, infections, circulatory disorders dominate diagnoses linked to risk—aligning with classic “can’t-miss” conditions.

  • Actionable focus areas: tighten documentation, maintain diagnostic vigilance (explicit differentials, safety-netting), and improve team situational awareness (handoffs, boarding risks, interruptions).

Practice pearls (ED-focused):

  • Document explicitly: decision rationale, differential (including “can’t-miss”), consultations, patient understanding, and clear return precautions.

  • Combat cognitive error: structured re-evaluation and diagnostic time-outs on high-risk complaints (fever, chest pain, head injury, limb ischemia).

  • Protect situational awareness: safer handoffs, reduce interruptions on disposition tasks, flag boarded/high-risk patients.

Injury/infection/circulatory complaints → lower threshold for repeat vitals, second exam, and escalation/observation when uncertainty remains.

Results:

  • Case set: 37,046 closed cases (2018–2022); 1,892 involved ED physicians with analyzable medico-legal info.

    • College complaints: 54% (1,019)

    • Civil actions: 27% (516)

    • Hospital complaints: 19% (357)

  • Peer-expert criticism: 1,165/1,892 (62%) of ED cases.

  • Outcome direction: >50% (52%) of complaints ended unfavorably for the physician.

  • Contributing factors in criticized cases (n=1,165):

    • Clinical decision-making: 64%

    • Situational awareness: 44%

    • Documentation issues: 42%

  • Common diagnosis categories tied to risk: injuries, infections, circulatory system disorders.

Methods:

  • Descriptive analysis of closed medico-legal cases involving ED physicians across Canada using CMPA data.

  • Timeframe: January 2018–December 2022.

  • Included hospital complaints, College complaints, civil actions; abstracted case descriptors and applied a contributing-factors framework.

Cortel-LeBlanc, M.A., Lemay, K., Chhabra, S., Yang, Q., Ji, J., Woods, S., Sherif, R.E. and Garber, G., 2025. Medico-legal risk in the emergency department. Canadian Journal of Emergency Medicine, pp.1-9.

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