A frequent concern among clinicians new to point-of-care ultrasound (POCUS) is the risk of malpractice. This fear often arises from equating POCUS with radiology-performed ultrasounds. Many worry that their image quality and interpretation will be held to the standards of an ultrasound technician and a radiologist, respectively. Fear of malpractice or defensive medicine significantly influences medical practice, but is this anxiety warranted for POCUS?
The Data
Three groups have evaluated malpractice cases in the emergency department involving POCUS. One group reviewed 659 cases from 1987 to 2007 and found only one case where the allegation was that the emergency physician failed to perform a POCUS. A second group evaluated 120 cases from 2008 through 2012 and found no reported cases of failure to interpret POCUS, or misdiagnoses. A third group analyzed 276 cases from December 2012 to January 2021 and found 19 malpractice cases, with the most common allegation being the failure to perform an ultrasound. There were no cases that clearly alleged the misinterpretation of POCUS.
A 2020 review assessed cases in the Westlaw database involving internal medicine, critical care, pediatrics, and family practice through October 1, 2019. The authors located 131 malpractice cases, none of which involved the use of POCUS in these specialties.
A 2024 Canadian study analyzed the 58,626 closed cases in the Canadian Medical Protective Association (CMPA) closed-case repository from 2012 through 2021. This study included civil litigation, hospital complaints, and complaints to the College of Medicine that did not result in a lawsuit.
The authors found 15 cases related to POCUS involving multiple specialties, with five being civil suits. Seven of these cases were due to the failure to perform a POCUS exam when indicated, while the other eight involved inadequate skill or poor documentation. It is unclear whether these cases resulted in lawsuits or were simply complaints not severe enough to warrant legal action. Additionally, Canada is less litigious than the U.S., making it difficult to determine if these cases would have resulted in lawsuits in the U.S.
The Analogy
Generalist physicians, such as family physicians, internists, and emergency physicians, often manage conditions that fall within a specialist’s expertise and typically do so effectively. Generalists recognize when a condition exceeds their scope and requires specialist consultation. For instance, generalists routinely interpret ECGs, but occasionally, an electrophysiologist’s expertise is needed for complex findings. Most hypothyroidism cases are treated by primary care physicians with excellent outcomes without requiring an endocrinologist.
Similarly, radiology- or cardiology-performed ultrasounds can be seen as consultative ultrasounds. Other types of physicians can adequately perform POCUS exams to answer specific, narrow clinical questions.
Liberalizing POCUS use ultimately benefits patients. Bedside clinicians trained in POCUS can obtain more clinical information than through physical exams alone, improving patient outcomes and increasing efficiency. Additionally, it reduces the need for specialist consultations for straightforward cases, conserving healthcare resources and costs. However, unexpected POCUS findings or a difficult exam may occasionally require a “radiology consult” for further interpretation.
Mitigating Malpractice
The most current data through 2021 are reassuring and encouraging. I found virtually no malpractice cases in the U.S. stemming from poor POCUS performance. Instead, the few POCUS-related cases should encourage more liberal use of POCUS in practice. However, if POCUS use increases across the house of medicine, it is possible that malpractice cases involving POCUS will rise over time.
This is not to imply we should throw the proverbial baby out with the bathwater. Instead, by implementing a robust POCUS program in our practice, we can mitigate the chances of a lawsuit. The following are strategies that, when implemented as part of a POCUS program, decrease the chance of error and consequently malpractice.
Training
Like any skill, POCUS requires training and practice to achieve proficiency. After completing a comprehensive hands-on course, physicians new to POCUS should begin using it and order confirmatory consultative imaging studies until they feel confident or are credentialed. The American College of Emergency Physicians recommends a minimum of 25 ultrasound studies reviewed for quality assurance.
Credentialing
Hospitals can mitigate malpractice risk by appropriately credentialing all POCUS providers. Credentialing should include a minimum number of training hours or residency training, and demonstration of proficiency through internal or external quality review. Specialty society guidelines should be followed when available. Ongoing Professional Practice Evaluation (OPPE) should be implemented to prevent skill degradation.
POCUS standardization
A policy dictating the standard views — the anatomy seen on a single POCUS image or clip — for a POCUS exam allows physicians to demonstrate adherence to hospital policy and national standards when performing the exam.
Image archival and documentation
Archiving images, whether to a Picture Archiving and Communication System or a middleware product, ensures that the images saved during the POCUS exam are available for review at any time. If there are questions about the accuracy of the interpretation of the POCUS exam, the archived images can be revisited. Archiving facilitates ongoing quality assurance and provider education. Additionally, having a report in the electronic medical record that accompanies a POCUS exam ensures that POCUS findings are documented and accessible to physicians involved in the patient’s future care.
Toward Broader Use of POCUS
POCUS performance and interpretation have not been shown to pose a significant malpractice risk, and current fears are likely exaggerated. However, as POCUS use grows, litigation involving POCUS may increase. Despite this, the benefits of POCUS to patients outweigh the fear of litigation.
By investing in comprehensive training, adhering to standardized protocols, ensuring robust documentation, and implementing quality assurance measures, healthcare systems can mitigate risks and maximize the benefits of POCUS.
Joshua Guttman, MD, is an associate professor in the Department of Emergency Medicine at Emory University School of Medicine in Atlanta.
Disclosures
Guttman is the founder and CEO of Peachtree POCUS, a POCUS consulting company.
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