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Cited by 48Medical Malpractice and Liability IssuesPatient Safety and Medication ErrorsClinical Reasoning and Diagnostic Skills

Defensive Healthcare Practice: Systematic Review of Qualitative Evidence

Open access
Lorenc, Theo, Khouja, Claire, Harden, Melissa, Fulbright, Helen, Thomas, James·2024·BMJ Open
DOI 10.1136/bmjopen-2024-085673PMC PMC11261683
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Abstract

Objective: To synthesise qualitative evidence on clinicians’ views and experiences of defensive practice. Design: Systematic review of qualitative data. Data sources: MEDLINE, Embase, PsycINFO, AMED, Maternity and Infant Care, CINAHL, ASSIA, Sociological Abstracts, Proquest Dissertations & Theses and PROSPERO were searched from 2000 to October 2023. Eligibility criteria: We included English-language studies of clinicians which reported qualitative data on the impact of litigation or complaints on clinical practice. Data extraction and synthesis: We coded findings data line by line using a grounded theory approach. We assessed quality using Hawker et al ’s tool and synthesised data thematically. Results: 17 studies were included. Participants identify a range of clinical decisions which may be defensively motivated, relating to diagnosis and documentation as well as to treatment. Defensive practice often relates to a diffuse sense of risk rather than the direct threat of litigation and may overlap with other motivations, such as perceived pressure from patients or the desire to avoid harm. Defensive practice is seen to be harmful in many ways, but again, these perceptions may gain force from broader narratives of mistrust and disempowerment, as much as from the risk of litigation. Conclusions: The idea of defensive practice, as enacted, is more complex than some theoretical accounts suggest and may often function to express broader concerns about the work of clinical care. The qualitative evidence calls into question the view of defensive practice as a key mediator linking litigation risk to inappropriate treatment and excess costs.

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  • Although these practices are often perceived as legally protective, they can delay diagnoses, increase errors, raise healthcare expenses, and undermine patient outcomes by diverting attention from timely clinical decision making.

    “Although these practices are often perceived as legally protective, they can delay diagnoses, increase errors, raise healthcare expenses, and undermine patient outcomes by diverting attention from timely clinical decision making [266].”

    From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [266]

    The Introduction describes defensive practice as an attempt to reduce litigation or complaints and says it may harm patient care and drive excess costs. The Discussion reports clinicians’ perceptions that litigation concerns can lead to suboptimal care, while cautioning against assuming large-scale effects. The passages do not establish delayed diagnoses, increased errors, or diversion from timely clinical decisions as the mechanism. Page numbers were not available in our copy. (LLM, conf=0.87)

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2 of the 51 references couldn’t be matched to a known paper.

Research works printed but not linked: 1

  1. [25]Bradder AM reflexivity in professional practise and the social construction of defensive medicine: a study of discourses of risk in medical practice [phd thesis] University of Liverpool 2007

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Authors
Lorenc, T., Khouja, C., Harden, M., Fulbright, H., & Thomas, J.
Affiliations
  • University of York (GB)
  • University College London (GB)
Corresponding author
Lorenc, Theo
ORCID
Venue
BMJ Open
Publisher
BMJ
Published
2024-07
Volume
14
Issue
7
Pages
e085673
ISSN
2044-6055 (ISSN-L)
DOI
10.1136/bmjopen-2024-085673
PMC
PMC11261683
OpenAlex
W4400804289
Cited by
48
References
51
Citations by year
2026: 35 · 2025: 13
FWCI
5.10
Type
journal article
Language
en
Open access
Licence
Locations
  • BMJ Open (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
  • HighWire Press Open Archive (submittedVersion)
Funders
NIHR Policy Research Programme (NIHR200701)
Topics
  • Health Sciences › Health Professions › Pharmacy › Medical Malpractice and Liability Issues
  • Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
  • Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
Keywords
defensive medicine, defensive practice, medical litigation, patient complaints, clinician experience, risk aversion, clinical decision-making, documentation, patient trust, inappropriate treatment
MeSH terms
Attitude of Health Personnel, Defensive Medicine, Humans, Qualitative Research

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