Rates and Characteristics of Paid Malpractice Claims Among US Physicians by Specialty, 1992-2014

Canadian legal cases in ophthalmology: a closer look at 40 years' worth of data

OBJECTIVE

To assess the characteristics of malpractice lawsuits against Canadian ophthalmologists and the predisposing factors leading to claims.

DESIGN

Retrospective case series.

METHODS

A systematic search of the 2 largest Canadian online legal databases, LexisNexis Canada and Westlaw Canada, was performed to collect cases against ophthalmologists in Canadian courts from 1977 to 2021.

RESULTS

This study comprised 68 legal cases, including 52 lawsuits, 14 cases appealed once, and 2 cases appealed twice. Most cases concerned surgical procedures (46.2%), followed by misdiagnoses or lack thereof (32.7%) and nonsurgical procedures (21.2%). Half the cases (n = 26) were immediately dismissed by the judge in favour of the ophthalmologist, though among the remaining half that proceeded to trial the majority (88.5%) were won by the patients. All appeals by patients were dismissed by the judge. The median monetary value of damages awarded was $308,202.

CONCLUSIONS

This study is the first to report on ophthalmology-involved medical litigation cases in Canada. Most cases were ruled in favour of the ophthalmologist, but most of those that were not immediately dismissed by the judge were ruled in favour of the plaintiff. Notably, a plurality of these cases argued for a lack of informed consent, and every case in which a lack was successfully pleaded was ruled in favour of the plaintiff, highlighting the importance of appropriate informed consent. The findings of this study give Canadian ophthalmologists insight into areas of practice that commonly lead to litigation and can aid in improving clinical practice and risk management.

Medical malpractice and epidural hematomas: a retrospective analysis of 101 cases in the United States

Background

Neurosurgeons face particularly high rates of litigation compared to physicians in other fields. Malpractice claims are commonly seen after mismanagement of life-threatening medical emergencies, such as epidural haematomas. Due to the lack of legal analysis pertaining to this condition, the aim of this study is to identify risk factors associated with litigation in cases relating to the diagnosis and treatment of epidural haematomas.

Materials and methods

Westlaw Edge, an online database, was used to analyze malpractice cases related to epidural haematomas between 1986 and 2022. Information regarding plaintiff demographics, defendant specialty, reason for litigation, trial outcomes, and payouts for verdicts and settlements were recorded. Comparative analysis between cases that returned a jury verdict in favour of the plaintiff versus defendant was completed.

Results

A total of 101 cases were included in the analysis. Failure to diagnose was the most common reason for litigation (n = 64, 63.4%), followed by negligent care resulting in an epidural haematoma (n = 44, 43.6%). Spine surgery (n = 29, 28.7%), trauma (n = 28, 27.7%), and epidural injection/catheter/electrode placement (n = 21, 20.8%) were the primary causes of haematomas. Neurosurgeons (n = 18, 17.8%) and anesthesiologists (n = 17, 16.8%) were the two most common physician specialties cited as defendants. Most cases resulted in a jury verdict in favour of the defense (n = 54, 53.5%). For cases ending in plaintiff verdicts, the average payout was $3 621 590.45, while the average payment for settlements was $2 432 272.73.

Conclusion

Failure to diagnose epidural haematomas is the most common reason for malpractice litigation, with neurosurgeons and anesthesiologists being the most common physician specialties to be named as defendants. More than half of all cases returned a jury verdict in favour of the defense and, on average, settlements proved to be more cost-effective than plaintiff verdicts.

Understanding Factors Associated with Paid Malpractice Claims in Plastic Surgery

BACKGROUND

Few studies have investigated malpractice broadly in the field of plastic surgery. The purpose of this analysis was to characterize plastic surgery malpractice cases and examine factors influencing malpractice case outcomes, thereby identifying areas of patient safety concern.

METHODS

The Candello database, which catalogs approximately 30% of all paid and unpaid malpractice claims in the United States, was used to obtain cases involving plastic surgery closed between 2009 and 2018. A total of 2674 cases were identified. A multivariable regression model was developed to analyze factors associated with a malpractice case closing with indemnity payment.

RESULTS

A total of 716 claims (26.8%) resulted in an indemnity payment. The clinical severity was determined to be high in 229 cases (8.6%). Emotional trauma [ n = 558 (20.9%)] was the most frequently cited injury category. Major differences between procedure groups were not observed, with consistent severity of injury across categories. Poor surgical technique, problems with communication among providers, inadequate informed consent, and deficient documentation were significant factors predictive of malpractice cases closing with payment. Issues with technical performance resulting in a known complication and patient factors were protective against paid claims.

CONCLUSIONS

The financial and clinical severity of malpractice claims in plastic surgery were relatively low overall. Multiple factors were found to be associated with a case closing with an indemnity payment. These data highlight the importance of the informed consent process and managing expectations in the clinical care of surgical patients.

Medical malpractice and cerebrospinal fluid shunts: An analysis of 36 cases

Many physicians, particularly neurosurgeons, face malpractice claims during their career. The aim of this paper is to identify which factors increase the risk of litigation and influence legal outcomes relating to cerebrospinal fluid shunt management. Westlaw, an online legal database, was used to identify all medico-legal cases pertaining to cerebrospinal fluid shunts. Information regarding plaintiff demographics, defendant specialties, reasons for litigation, and trial outcomes were analysed. Thirty-six cases met criteria for inclusion. Most cases returned a defence verdict (44.4%), with delayed treatment or failure to appropriately treat patients with shunts the most common reason for litigation (66.7%). The average plaintiff verdict payout was $4,888,136.75 and average settlement $1,362,307.69. Delay or failure to treat resulted in the largest average payouts for plaintiff verdicts and settlements ($5,329,299.14 and $1,531,500.00, respectively).

Medico-Legal Implications of Video Recordings of Clinic Visits in Malpractice Claims Against Medical Providers

OBJECTIVE

Although audio-video recordings of clinic visits improve patient satisfaction and recall, the associated presumed risk of increased malpractice claims limits their use. In this study, we identified whether video recording clinic visits was associated with increases in professional liability claims.

METHODS

From 2015 to 2017, the institution's loss run was analyzed, and the rates of medical malpractice claims per physician-year were compared between physicians who used video recordings of clinic visits (V-RoCs) and those who did not. The term "users" was applied to all physicians whose mean percentage of patient visits with video recording was greater than the mean percentage for the practice overall.

RESULTS

Over three years, 15,254 patients used V-RoCs. The use of video recordings for clinic visits increased at a rate of 23% per year. No association was found between video recordings and increased malpractice claims. The rate of all claims between users and nonusers did not differ significantly (P=0.66). Of seven paid claims or lawsuits from 2000 to 2017, none were against physicians who used video recordings.

CONCLUSION

Video recording of patient-physician encounters was not associated with an increase in malpractice lawsuits. According to federal law, a patient can legally record a clinic encounter without physician consent, which has many ethical implications. Formalizing the recording process is beneficial for both parties and allows the resource to be used to its maximum potential.

Knee'd to Know Basis: Informed Consent in Total Hip and Knee Arthroplasty

Informed consent is the process by which a medical provider explains the benefits, risks, and alternatives to a proposed medical intervention. It is a crucial part of maintaining patient autonomy and is particularly important in the context of elective surgical procedures, such as joint arthroplasty. The goal of this article is to review the topic of informed consent in the context of total joint arthroplasty. In this review, we discuss informed consent in general, considerations for informed consent in general arthroplasty procedures, and special 12 considerations for both hip and knee arthroplasty.

An analysis of medical malpractice claims against medical oncologists from a national database: Implications for safer practice

Malpractice claims data include valuable information about patient safety. We used mixed methods to analyze claims against medical oncologists (MO) from 2008 to 2019 using a national database. MO claims were compared to a group of other internal medicine subspecialties (OIMS). Logistic regression was used to examine correlates of closing with an indemnity payment. A subset of claims against MO were thematically analyzed using a validated safety incident taxonomy as a framework. 456 claims against MO were compared with 5771 claims against OIMS. MO claims closed with indemnity payments 29.8% of the time versus OIMS 30.3% (p = 0.87). Median MO and OIMS indemnity payments were similar ($190,591 vs. $233,432; p = 0.20). Correlates of MO claims closing with payment included patient assessment, communication among providers, and safety and security as contributing factors. Thematic analysis identified provider cognitive error, adverse drug events and relational problems as the most common safety incidents. MO malpractice claims have similar outcomes to OIMS. We demonstrate the proof-of-concept of applying a safety incident taxonomy to medical malpractice. Finding ways to reduce patient exposure to provider cognitive errors, adverse drug reactions, and communication breakdowns should be strategic priorities for safer cancer care.

Characteristics and trends of medical malpractice claims in Japan between 2006 and 2021

Classification and analysis of existing data on medical malpractice lawsuits are useful in identifying the root causes of medical errors and considering measures to prevent recurrence. No study has shown the actual prevalence of all closed malpractice claims in Japan, including the number of cases and their trial results. In this study, we illustrated the recent trends of closed malpractice claims by medical specialty, the effects of the acceptance rates and the settlements and clarified the trends and characteristics. This was a descriptive study of all closed malpractice claims data from the Supreme Court in Japan from 2006-2021. Trends and the characteristics in closed malpractice claims by medical specialty and the outcomes of the claims, including settlements and judgments, were extracted. The total number of closed medical malpractice claims was 13,340 in 16 years, with a high percentage ending in settlement (7,062, 52.9%), and when concluding in judgment (4,734, 35.3%), the medical profession (3,589, 75.8%) was favored. When compared by medical specialty, plastic surgery and obstetrics/gynecology were more likely resolved by settlement. By contrast, psychiatry cases exhibited a lower likelihood of settlement, and the percentage of cases resulting in unfavorable outcomes for patients was notably high. Furthermore, there has been a decline in the number of closed medical malpractice claims in Japan in recent years compared to the figures observed in 2006. In particular, the number of closed medical malpractice claims in obstetrics/gynecology and the number of closed medical malpractice claims per 1,000 physicians decreased significantly compared to other specialties. In conclusion, half of the closed malpractice claims were settled, and a low percentage of patients won their cases. Closed medical malpractice claims in Japan have declined in most medical specialties since 2006. Additionally, obstetrics/gynecology revealed a significant decrease since introducing the Obstetrics/Gynecology Medical Compensation System in 2009.

Bladder exstrophy-epispadias complex related litigation: A legal database review

OBJECTIVE

To review the nature and extent of bladder exstrophy-epispadias related malpractice litigation in the United States.

METHODS

Two legal databases (Nexis Uni, WestLaw) were reviewed for state and federal cases using the terms "bladder exstrophy", "cloacal exstrophy", "epispadias", in combination with "medical malpractice", or "negligence", or "medical error", or "complication", or "malpractice", or "tort". Databases were queried from 1948 to 2022 and reviewed for medical and legal details.

RESULTS

Our search yielded 16 unique legal cases with 6 fitting established criteria for analysis. Urology and paediatric urologists were named in 50% of cases as were community medical systems. Cause for lawsuit included negligence in surgical performance (50%), primary closure of exstrophy (33%), and post-operative care (50%). Settlement agreement was reached in one case (17%). Outcomes favoured the physician in 60% of trials. Lawsuits alleging negligent surgical performance and/or post-operative care exclusively named urologists with outcomes favouring the surgeon in 66% of cases. The settlement payment (n = 1) was $500,000 and monetary damages (n = 1) equated to $1.3 million.

CONCLUSIONS

Malpractice litigation related to BEEC treatment is rare. Trial outcomes favour the medical provider. Cases that resulted in financial liability successfully alleged avoidable negligence resulting in irreversible physical damage. The authors recommend families with BEEC seek board-certified paediatric urologists experienced in treating this complex and/or Bladder Exstrophy Centers of Excellence. Further, we recommend surgeons treating BEEC properly educate patients and families on the severity of this major birth defect including its lifelong implications and need for surgical revisions.

Medical malpractice claims in Hepatology: Rates, Reasons, and Results

BACKGROUND

Clinicians are motivated to provide safe, high-quality care to patients with chronic liver disease. This includes the desire to avoid litigation. Data are limited regarding the actual sources of medicolegal risk in chronic liver disease.

METHODS

We conducted a review of a national liability insurer (Candello) with an additional granular analysis of our institution's registry of liability claims. We included closed cases involving chronic liver disease-related encounters between 2012 and 2021. We determined rates of legal claims from a denominator of unique patients with cirrhosis or transplant care seen over the study period.

RESULTS

Local database: We retrieved 39 claims of which 15 involved patients with non-cirrhotic chronic liver disease, 13 involved cirrhosis (0.06% incidence), and 11 involved patients who underwent transplantation (0.6% incidence). Most claims involved periprocedural complications. Others included adverse reactions to prophylactic plasma transfusion, medication-induced HE, and falls/fractures.

NATIONAL DATABASE

We found 94 claims related to liver disease out of 102,575 (0.09%) total claims. Overall, 56% involved diagnosis-related issues (failure/delay in ordering a diagnostic test, failure to appreciate and reconcile a symptom/sign or result, or the misinterpretation of a diagnostic study). Miscommunication between providers and between providers and patients was implicated in 22% of cases. Patient behavior-related factors (nonadherence with scheduled appointments, treatments, or diagnostic testing) factored in 20% of cases. Selection or the management of therapy played a role in 7% of cases. Very rarely were cases associated with technical skill (4%), house staff supervision (3%), or weekend/holiday care (1%). Fifty-one (55%) claims involved HCC.

CONCLUSION

We provide the rates and reasons for medical malpractice claims in hepatology.

Malpractice litigation surrounding in vitro fertilization in the United States: a legal literature review

IMPORTANCE

Analysis of malpractice lawsuits that involve in vitro fertilization (IVF) can provide insight into the breadth of legal challenges faced by IVF clinics and the patient harms and financial consequences that can result from alleged errors in practice.

OBJECTIVE

We aimed to review malpractice litigations involving IVF and identify common themes in plaintiff allegations and defense arguments.

EVIDENCE REVIEW

We queried Nexis Uni, Westlaw, and CourtListener legal databases to collect records from malpractice litigations involving IVF. The nature of the cases, allegations, and outcomes were abstracted from court documents.

FINDINGS

Of the 447 cases identified in the query, 53 involved both malpractice and IVF, occurring between 1993 and 2022. Defendants included a reproductive endocrinologist in 19 (35.8%) cases, an academic institution in 17 (32.1%) cases, embryology personnel in 9 (17.0%) cases, and nursing staff in 2 (3.8%) cases. Twenty-four (45.3%) cases involved embryology errors (e.g., lost specimens and incorrect sperm donor), 11 (20.8%) preimplantation genetic testing errors (e.g., child born with genetic illness despite testing), 6 (11.3%) medical or surgical complications (e.g., ovarian hyperstimulation syndrome), 4 (7.5%) misdiagnoses (e.g., malignancy before cycle start), 3 (5.6%) misrepresentations of IVF outcomes, 2 (3.8%) medical eligibility screening issues (e.g., medical comorbidities in a gestational carrier), 2 (3.8%) confidentiality breaches, and 1 (1.9%) case of discrimination. The most common secondary claims were negligence (23 cases, 16.4% of all claims), breach of contract (13, 9.3%), lack of informed consent (11, 7.9%), and negligent infliction of emotional distress (11, 7.9%). Twenty-nine (54.7%) cases were decided in favor of the defending IVF clinic or provider, 13 (24.5%) cases were decided in favor of the plaintiff, and 11 (20.8%) involved ongoing proceedings. Financial awards ranged from $4171 to $14,975,000, with the largest monetary award resulting from a cryostorage accident class action lawsuit.

CONCLUSION

In vitro fertilization malpractice claims are varied, with the most common issues involving embryology laboratory processes and genetic testing errors. Some errors may be avoidable with increased vigilance and implementation of stringent laboratory and clinical guidelines. Understanding jurisdiction-specific legislation and court processes may also assist IVF providers in navigating the malpractice litigation process.

RELEVANCE

This comprehensive review of IVF litigation may have the potential to promote practices that protect both providers and patients.

Involvement in a Personal Injury Claim Is Associated With More Pain and Delayed Return to Work After Elective Nonsurgical or Surgical Treatment for Hand or Wrist Disorders: A Propensity Score-matched Comparative Study

BACKGROUND

A small proportion of patients treated for a hand or wrist condition are also involved in a personal injury claim that may or may not be related to the reason for seeking treatment. There are already indications that patients involved in a personal injury claim have more severe symptoms preoperatively and worse surgical outcomes. However, for nonsurgical treatment, it is unknown whether involvement in a personal injury claim affects treatment outcomes. Similarly, it is unknown whether treatment invasiveness affects the association between involvement in a personal injury claim and the outcomes of nonsurgical treatment. Finally, most studies did not take preoperative differences into account.

QUESTIONS/PURPOSES

(1) Do patients with a claim have more pain during loading, less function, and longer time to return to work after nonsurgical treatment than matched patients without a personal injury claim? (2) Do patients with a personal injury claim have more pain, less function, and longer time to return to work after minor surgery than matched patients without a personal injury claim? (3) Do patients with a personal injury claim have more pain, less function, and longer time to return to work after major surgery than matched patients without a personal injury claim?

METHODS

We used data from a longitudinally maintained database of patients treated for hand or wrist disorders in the Netherlands between December 2012 and May 2020. During the study period, 35,749 patients for whom involvement in a personal injury claim was known were treated nonsurgically or surgically for hand or wrist disorders. All patients were invited to complete the VAS (scores range from 0 to 100) for pain and hand function before treatment and at follow-up. We excluded patients who did not complete the VAS on pain and hand function before treatment and those who received a rare treatment, which we defined as fewer than 20 occurrences in our dataset, resulting in 29,101 patients who were eligible for evaluation in this study. Employed patients (66% [19,134 of 29,101]) were also asked to complete a questionnaire regarding return to work. We distinguished among nonsurgical treatment (follow-up at 3 months), minor surgery (such as trigger finger release, with follow-up of 3 months), and major surgery (such as trapeziectomy, with follow-up at 12 months). The mean age was 53 ± 15 years, 64% (18,695 of 29,101) were women, and 2% (651 of 29,101) of all patients were involved in a personal injury claim. For each outcome and treatment type, patients with a personal injury claim were matched to similar patients without a personal injury claim using 1:2 propensity score matching to account for differences in patient characteristics and baseline pain and hand function. For nonsurgical treatment VAS analysis, there were 115 personal injury claim patients and 230 matched control patients, and for return to work analysis, there were 83 claim and 166 control patients. For minor surgery VAS analysis, there were 172 personal injury claim patients and 344 matched control patients, and for return to work analysis, there were 108 claim and 216 control patients. For major surgery VAS analysis, there were 129 personal injury claim patients and 258 matched control patients, and for return to work analysis, there were 117 claim and 234 control patients.

RESULTS

For patients treated nonsurgically, those with a claim had more pain during load at 3 months than matched patients without a personal injury claim (49 ± 30 versus 39 ± 30, adjusted mean difference 9 [95% confidence interval (CI) 2 to 15]; p = 0.008), but there was no difference in hand function (61 ± 27 versus 66 ± 28, adjusted mean difference -5 [95% CI -11 to 1]; p = 0.11). Each week, patients with a personal injury claim had a 39% lower probability of returning to work than patients without a claim (HR 0.61 [95% CI 0.45 to 0.84]; p = 0.002). For patients with an injury claim at 3 months after minor surgery, there was more pain (44 ± 30 versus 34 ± 29, adjusted mean difference 10 [95% CI 5 to 15]; p < 0.001), lower function (60 ± 28 versus 69 ± 28, adjusted mean difference -9 [95% CI -14 to -4]; p = 0.001), and 32% lower probability of returning to work each week (HR 0.68 [95% CI 0.52 to 0.89]; p = 0.005). For patients with an injury claim at 1 year after major surgery, there was more pain (36 ± 29 versus 27 ± 27, adjusted mean difference 9 [95% CI 4 to 15]; p = 0.002), worse hand function (66 ± 28 versus 76 ± 26, adjusted mean difference -9 [95% CI -15 to -4]; p = 0.001), and a 45% lower probability of returning to work each week (HR 0.55 [95% CI 0.42 to 0.73]; p < 0.001).

CONCLUSION

Personal injury claim involvement was associated with more posttreatment pain and a longer time to return to work for patients treated for hand or wrist disorders, regardless of treatment invasiveness. Patients with a personal injury claim who underwent surgery also rated their postoperative hand function as worse than similar patients who did not have a claim. Depending on treatment invasiveness, only 42% to 55% of the personal injury claim patients experienced a clinically relevant improvement in pain. We recommend that clinicians extensively discuss the expected treatment outcomes and the low probability of a clinically relevant improvement in pain with their personal injury claim patients and that they broach the possibility of postponing treatment.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Litigation involving patients with slipped capital femoral epiphysis

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is a hip disorder of late childhood and adolescence. Litigation involving SCFE may occur, as it is frequently diagnosed late, and/or may be temporally related to an injury. The purpose of this study was to review litigation cases involving SCFE in the US, focusing on the type of litigation (professional, premise, or product liability), the outcome of the litigation and indemnity payouts.

METHODS

Cases of litigation involving SCFE were identified using 5 legal databases and Google Scholar searching for the term "slipped capital femoral epiphysis". These databases originated as early as 1973. The data collected was the alleged complaint, type of defendant, outcome, state where filed, and amount of indemnity payout. Payout amounts were converted to 2020 US$. Statistical analyses were performed with SYSTAT® 10 software.

RESULTS

There were 135 unique cases identified which involved professional liability (103), premise liability (30), both premise and professional liability (1), and product liability (1). Complaints for professional liability cases were alleged failure in diagnosis (71), inappropriate treatment (14), both diagnosis and treatment (12), and others (7). The delay in those with an alleged late diagnosis (37 cases) was 5.8 months. The three most common specialties named as defendant(s) were primary care (31%), orthopaedic surgeons (29%), and radiologists (16%). The primary allegations against non-orthopaedic surgeons were failure in diagnosis (89%) as opposed to orthopaedic surgeons where the complaints of alleged failures in diagnosis and inappropriate treatment were equal (50%). The geographic region of the filed cases was the Northeast (44%), South (24%), Midwest (16%), and West (16%). There were no differences between premise and professional liability cases by geographic region. The overall outcome was favorable for the defendant(s) in 53% and the plaintiff in 47%; the defense prevailed in 60% of the professional liability but only 33% of the premise liability cases. The indemnity payout amount (for the 52 cases where known) averaged $1.28 million. Payout was higher in the complaints for professional compared to premise liability ($1.5 vs. $0.9 million). The average payout for those with and without avascular necrosis was $2.97 million vs. $1.02 million. For the professional liability claims, indemnity payout was most frequent in the Western US. It must be remembered that this study only represents law suits filed in the US court system. It does not include cases that might have been resolved prior to any legal action as those cases are not publicly available.

CONCLUSIONS

Reported litigation involving SCFE patients involved claims of professional liability in 77% and premise liability in 22% of located cases. Due to significant exposure, this study should serve as a reminder to all health care providers to include SCFE in the differential diagnosis of knee/thigh pain in adolescents.

Race Differences in a Malpractice Event Database in a Large Healthcare System

OBJECTIVES

This study aimed to determine whether potential malpractice events reported by employees, malpractice events involving claims, and malpractice lawsuits differ based on patient race in a large 10-hospital healthcare system.

METHODS

Data in a healthcare system's malpractice database from July 1, 2012, to June 30, 2017, were stratified by patient race using "Black," "White," and "other" categories. χ2 Goodness-of-fit tests were used to compare differences in race proportions in employee-reported observations of events that could lead to payment of a claim, claims not involving the court, and lawsuits involving the court.

RESULTS

There were significantly more employee-reported observations and claims for White patients and significantly fewer observations and claims for Black patients than expected based on the race proportions in the overall healthcare system patient population ( P < 0.001). There were no significant race differences in lawsuits (Black patients, P = 0.146; White patients, P = 0.061; other patients, P = 0.458). Four of the 10 hospitals in the healthcare system had significant race differences in potential malpractice events (hospital A, P < 0.001; hospital B, P = 0.011; hospital E, P < 0.001; hospital G, P = 0.010).

CONCLUSIONS

Our findings reveal the existence of race differences in potential malpractice events in a large healthcare system. By proactively investigating, understanding, and addressing racial disparities in patient safety events, including those recorded in malpractice databases, healthcare systems can help advance initiatives to provide high-quality and equitable care to patients.

Ophthalmic Trauma Malpractice in the Ophthalmic Mutual Insurance Company Database

PURPOSE

To review ophthalmic trauma malpractice claims in the Ophthalmic Mutual Insurance Company (OMIC) database to determine the frequency and causes of litigation.

METHODS

A retrospective case series analysis of ophthalmic trauma claims from 2009 to 2019 was completed. Cases were selected only if the injury was secondary to trauma (e.g., fall, gunshot wound, paintball injury, etc.); iatrogenic traumatic surgical injuries were excluded.

RESULTS

31 closed cases associated with 40 total claims related to ophthalmic trauma out of 2565 claims (1.56%) in the OMIC database were analysed. 13 of the 31 cases (41.9%) were decided for the plaintiff. In decisions for the plaintiff, the median settlement amount was $330,000 (range $125,000-$1,000,000). The most frequent initial diagnoses were corneal abrasion (n = 10), hyphema (n = 5) and open-globe injury (n = 5), and the most common final diagnoses were endophthalmitis (n = 8), intraocular foreign body (n = 7) and retinal detachment (n = 7). The most common causes of malpractice litigation were a delay in referral or follow-up (n = 11) and failure to get appropriate imaging (n = 8). In the 13 cases decided for the plaintiff, experts concluded nine did not meet standard of care.

CONCLUSIONS

Ophthalmic trauma malpractice claims are very uncommon in the United States, however, the payout is higher than non-trauma settlements, and approximately 40% of cases were decided for the plaintiff. Care could be improved with a careful history and complete ophthalmic examination (with dilated fundoscopy), imaging in appropriate patients, meticulous documentation, and early sub-specialist referral when the diagnosis or management plan was unclear.

Malpractice Claims and Incident Reporting: Two Faces of the Same Coin?

Incident reporting is an important method to identify risks because learning from the reports is crucial in developing and implementing effective improvements. A medical malpractice claims analysis is an important tool in any case. Both incident reports and claims show cases of damage caused to patients, despite incident reporting comprising near misses, cases where no event occurred and no-harm events. We therefore compare the two worlds to assess whether they are similar or definitively different. From 1 January 2014 to 31 December 2021, the claims database of Policlinico Universitario A. Gemelli IRCCS collected 843 claims. From 1 January 2020 to 31 December 2021, the incident-reporting database collected 1919 events. In order to compare the two, we used IBNR calculation, usually adopted by the insurance industry to determine loss to a company and to evaluate the real number of adverse events that occurred. Indeed, the number of reported adverse events almost overlapped with the total number of events, which is indicative that incurred-but-not-reported events are practically irrelevant. The distribution of damage events reported as claims in the period from 1 January 2020 to 31 December 2021 and related to incidents that occurred in the months of the same period, grouped by quarter, was then compared with the distribution of damage events reported as adverse events and sentinel events in the same period, grouped by quarter. The analysis of the claims database showed that the claims trend is slightly decreasing. However, the analysis of the reports database showed that, in the period 2020-2021, the reports trend was increasing. In our study, the comparison of the two, malpractice claims and incident reporting, documented many differences and weak areas of overlap. Nevertheless, this contribution represents the first attempt to compare the two and new studies focusing on single types of adverse events are, therefore, desirable.

Neuro-ophthalmology malpractice: A review of the Westlaw Database

BACKGROUND

Neuro-ophthalmologic conditions are at a higher risk of misdiagnosis compared to other ophthalmic conditions. Increased awareness of the most common diagnostic errors in neuro-ophthalmology that lead to malpractice claims can allow ophthalmologists to further improve their diagnostic workup to reduce delays in diagnosis and management, while also mitigating the risk of litigation.

METHODS

Malpractice trials in the Westlaw Legal Database that involved cases of neuro-ophthalmologic diagnostic errors or failures by ophthalmologists were included in this study.

RESULTS

A total of 43 cases were included, all citing failure to diagnose as the main reason for litigation. The most common diagnoses missed were cerebrovascular pathologies (30.2%), intracranial tumours (27.9%) and giant cell arteritis (25.6%). The majority of verdicts were in favour of the defendants (48.8%). After adjusting for inflation, the average amount awarded was $1,952,154.

CONCLUSION

Nearly half of the cases resulted in a defendant verdict. Settlement and plaintiff verdicts were costly, with average awards of approximately two million inflation-adjusted dollars. Failure to diagnose cerebrovascular pathologies was the most common diagnostic error followed by failure to diagnose intracranial tumours and giant cell arteritis. It is crucial for ophthalmologists to be aware of the most common pitfalls that lead to misdiagnosis or delays in diagnosis of neuro-ophthalmologic conditions.

Impact of the medical care act amendment on the medical malpractice litigation in Taiwan

Medical malpractice leads to medical criminal liability and claims. The national data of medical criminal liabilities across various specializations, before and after the Medical Care Act amendment, was lacking in Taiwan. The aim of this study is to clarify the impact of the law amendment. A comprehensive retrospective analysis of medical crimes was conducted from January 2001 to December 2020 in Taiwan. The number of medical criminal litigation, defendants, people who plead guilty, conviction rate, and punishment sentences were analyzed. Additionally, the number of practicing physicians in the year was used as the baseline to determine the rate of the accused and guilty rate per 10,000 physician-years, respectively. From 2001 to 2020, there were 249 criminal litigations of medical professionals, which gave rise to 335 defendants. The proportion of defendants by specialization was 19.1% in internal medicine, 26.3% in surgery and orthopedics, 11.9% in obstetrics and gynecology, 3.3% in pediatrics, 25.7% in physicians (who were not related to the aforementioned 4 specializations), and 13.7% in non-physician staff. After the amendment to the Medical Care Act in 2017, the accused rates per 10,000 physician-years decreased significantly in aggregate and by specialization between 2016 and 2020; the guilty rate per 10,000 physician-years during 2016 to 2020 was the minimum, compared to the past. The amendment to the Medical Care Act in 2017 reduced the number of vexatious criminal proceedings. The amendment also reduced criminal liabilities by reducing the guilty rate during 2016 to 2020, compared to the previous period.

Malpractice Litigation in Hand Surgery: A Comprehensive Nationwide Analysis

BACKGROUND

The circumstances surrounding claims against hand surgeons have not been elucidated in the literature. The purpose of this study was to analyze trends in malpractice litigation regarding hand surgery through a nationwide legal database.

METHODS

The Westlaw legal research database was queried for verdicts and settlements between 1985 and 2017 for hand surgery-related malpractice cases. Cases were included if the hand surgeon was sued for malpractice. Procedure type and complications and/or adverse events that resulted in litigation were recorded. Patient characteristics, state, date of case, case outcomes, and indemnity payment were also noted. All dollar amounts were adjusted to 2017 values using the Consumer Price Index.

RESULTS

In all, 171 cases (35 states) were included. The most frequently litigated surgeries were carpal tunnel releases followed by fracture treatment. Nerve injury was the predominant cause of litigation. The median nerve was predominantly injured, followed by the ulnar and radial nerves. In fracture surgery, malunion was the predominant cause, followed by weakness, nerve injury, and infection. In total, 72.5% of cases yielded verdicts in favor of the defense, 21.6% favored the plaintiff, and 5.9% were settled. Indemnity varied between $7800 and $8.99 million, averaging $570,397 for cases when the jury ruled in favor of the plaintiffs. Settled cases averaged $1,140,527.

CONCLUSIONS

Malpractice litigation has substantial financial implications on surgeons and the health care system. Litigation arises most commonly from routine procedures (carpal tunnel release and fracture fixation) rather than complex surgical cases, potentially due to the high variability in operating surgeon subspecialization, with discrepant training.

Trends and Developments in Medical Liability Claims in The Netherlands

Recent data on number of claims, final judgement of claims and their costs are scarce. This study analyzes 15 years of malpractice claims in the Netherlands. All claims filed, and all claims closed by two insurance companies (which insure approximately 95% of all hospitals in the Netherlands) between 2007–2021 are included. Trends in number of claims, medical specialties involved, final judgements and costs from malpractice claims are analyzed, as well as the impact of COVID-19 on malpractice claims. In total, 20,726 claims were filed and 21,826 claims were closed. Since 2013, the number of claims filed decreased. Of all claims filed, 64% were aimed at surgical specialties and 18% at contemplative specialties. Of all claims closed, 24.49% were accepted, 19.26% were settled and 48.94% got rejected. The financial burden of all claims closed quadrupled between 2007 and 2021; this increase was caused by rare cases with excessively high costs. Since the COVID-19 pandemic, we observed a decrease in the number of claims filed, and the number of incidents reported. This study provides valuable insights into trends and developments in the number and costs of liability claims, which is the first step towards improving patient safety and preventing incidents and malpractice claims.

The National Practitioner Database Malpractice Study of Severity of Alleged Malpractice Injuries Trends 2008-2018

This research examined trends and severity of alleged injury in malpractice over a 10-year period. An understanding of the severity of patient outcomes is important to gauge improvements in care delivery. Analysis of the National Practitioner Database (NPDB) investigated malpractice payments from 2008 to 2018 by physicians, advanced nurse practitioners, and registered nurses and assessed the relationship of years of practice on the severity of alleged malpractice injury. Malpractice payments over the study period, primarily represented payments for significant permanent or major permanent injuries (25.97%) or death (32.74%). Claims overall have shown a decline, including claims by the severity of malpractice injury, for most outcomes. The clinicians represented in the NPDB with >15 years of practice have greater odds for severity of malpractice injuries classified as minor permanent injury and significant permanent injury than those clinicians represented in the NPDB with fewer years of practice. Top allegation categorizations for malpractice payment were diagnostics, treatment, and surgery related for 4 of the severities of alleged injury.

Medical malpractice and gastrointestinal endoscopy

PURPOSE OF REVIEW

Medical liability is a perennial issue that most physicians will face at some point in their careers. Gastroenterologists routinely perform endoscopic procedures to aid in the diagnosis and treatment of their patients. Advances in endoscopic techniques and technology have accelerated movement of the field into a more surgical realm. These developments warrant consideration of pitfalls that may expose gastroenterologists to liability. This review will explore trends in malpractice facing gastroenterologists and offer strategies to deliver high quality and safe patient care.

RECENT FINDINGS

Despite being a procedure-oriented subspeciality, only a minority of malpractice claims against gastroenterologists are related to procedures. Diagnostic error is among the most prevalent reason for lawsuits. The consequences of malpractice are costly due litigation and indemnity as well as the increase in defensive medical practice. Improving diagnostic quality, optimizing informed consent, and enhancing patient-physician communication are important elements of risk mitigation.

SUMMARY

Understanding the important role that diagnosis plays in medical liability allows physicians to better evaluate risk and apply deliberate decision-making in order to practice confidently.

Reevaluating Innovations in Medical Student Neurosurgery Education: Lessons Learned Today from Data Collected Before COVID-19

OBJECTIVE

Virtual learning has made neurosurgery education more available to medical students (MSs) of all stages than ever before. We aimed to evaluate the impact of on-site learning in order to assess whether a return to this method of teaching, when safe, is warranted for MSs of all years.

METHODS

Registrants of the 2019 MS Neurosurgery Training Camps were sent precourse and postcourse surveys to assess changes in self-assessed confidence in concrete neurosurgical skills. Data were analyzed using a 2-tailed paired Student's t-test for continuous variables. A P value <0.05 was considered significant.

RESULTS

The 2019 Training Camp had 105 attendees, of whom 94 (89.5%) completed both surveys. Students reported statistically significant improvements in every surveyed skill area, except for understanding what is and is not sterile in an operating room. The cohort of MS 3/4 students indicated a postcourse decrease in confidence in their ability to understand what is and is not sterile in an operating room (93.69 ± 16.41 vs. 86.20 ± 21.18; P < 0.05). MS 3/4 students did not benefit in their ability to perform a neurologic examination or tie knots using a 1-handed technique.

CONCLUSIONS

Neurosurgical education initiatives for MSs should continue to be developed. Hands-on neurosurgical training experiences for MSs serve as a valuable educational experience. Improvement in training models will lead to capitalizing on MS education to better improve readiness for neurosurgical residency without concern for patient safety.

Surgical Error Compensation Claims as a Patient Safety Indicator: Causes and Economic Consequences in the Murcia Health System, 2002 to 2018

OBJECTIVES

Compensation claims are a useful source of information on patient safety research. The purpose of this study was to determine the main causes of surgical compensation claims and their financial impact on the health system.

METHODS

A descriptive observational study with analytical components was carried out on compensation claims brought against the surgical area of the Murcia Health System between 2002 and 2018. We analyzed the frequency, causes, consequences, locations and surgical settings of these claims, the time of judicial procedure, and compensation adjusted to the Consumer Price Index.

RESULTS

There were 1172 compensation claims. "orthopedic surgery and traumatology" (27.4%), "gynecology and obstetrics" (25.7%), and "general surgery" (17.2%) were the main surgical settings involved. The most frequent causes were surgical error (42.4%) and treatment error (30.9%). The main sequelae were musculoskeletal (20.0%), neurological (17.7%), and obstetric (17.7%). The average time from incident to resolution of claims was 6.3 years. A total of 20.1% of these claims were successful, particularly those involving retained surgical foreign bodies (71.4% successful claims; P < 0.001). The total compensation paid was €56,338,247 (an average of €17,207 per claim). Compensation was higher in cases with respiratory sequelae (median, 131,600; P = 0.033), death (75,916; P < 0.001), and neurological (60,000; P = 0.024).

CONCLUSIONS

Compensation claims associated with surgical procedures are made on a variety of grounds. They are drawn-out proceedings, and patients are only successful in 20% of cases.

Trends and Contributing Factors in Medicolegal Cases Involving Spine Surgery

STUDY DESIGN

Retrospective descriptive study.

OBJECTIVE

The aim of this study was to describe closed medicolegal cases involving physicians and spine surgery in Canada from a trend and patient safety perspective.

SUMMARY OF BACKGROUND DATA

Spine surgery is a source of medicolegal complaints against surgeons partly owing to the potential severity of associated complications. In previous medicolegal studies, researchers applied a medicolegal lens to their analyses without applying a quality improvement or patient safety lens.

METHODS

The study comprised a 15-year medicolegal trend analysis and a 5-year contributing factors analysis of cases (civil legal and regulatory authority matters) from the Canadian Medical Protective Association (CMPA), representing an estimated 95% of physicians in Canada. Included cases were closed by the CMPA between 2004 and 2018 (trends) or 2014 and 2018 (contributing factors). We fit a linear trend line to the annual rates of spine surgery cases per 1000 physician-years of CMPA membership for physicians in a neurosurgery or orthopedic surgery specialty. We then applied an ANOVA type III sum of squares test to determine the statistical significance of the annualized change rate over time. For the contributing factors analysis, we reported descriptive statistics for patient and physician characteristics, patient harm, and peer expert criticisms in each case.

RESULTS

Our trend analysis included 340 cases. Case rates decreased significantly at an annualized change rate of -4.7% (P  = 0.0017). Our contributing factors analysis included 81 civil legal and 19 regulatory authority cases. Most patients experienced health care-related harm (89/100, 89.0%). Peer experts identified intraoperative injuries (29/89, 32.6%), diagnostic errors (14/89, 15.7%), and wrong site surgeries (16/89, 18.0%) as the top patient safety indicators. The top factor contributing to medicolegal risk was physician clinical decision-making.

CONCLUSION AND RELEVANCE

Although case rates decreased, patient harm was attributable to health care in the majority of recently closed cases. Therefore, crucial opportunities remain to enhance patient safety in spine surgery.Level of Evidence: 4.

Poor compliance documenting informed consent in trauma patients with distal radius fractures compared to elective total knee arthroplasty

Background

The purpose of this study was (1) to evaluate the adequacy of informed consent documentation in the trauma setting for distal radius fracture surgery compared with the elective setting for total knee arthroplasty (TKA) at a large public hospital and (2) to explore the relevant guidelines in New Zealand relating to consent documentation.

Methods

Consecutive adult patients (≥16 years) undergoing operations for distal radius fractures and elective TKA over a 12‐month period in a single‐centre were retrospectively identified. All medical records were reviewed for the risks and complications recorded. The consent form was analysed using the Flesch Reading Ease Score (FRES) and the Simple Measure of Gobbledygook (SMOG) index readability scores.

Results

A total of 133 patients undergoing 134 operations for 135 distal radius fractures and 239 patients undergoing 247 TKA were included. Specific risks of surgery were recorded significantly less frequently for distal radius fractures than TKA (43.3% versus 78.5%, P < 0.001). Significantly fewer risks were recorded in the trauma setting compared to the elective (2.35 ± 2.98 versus 4.95 ± 3.33, P < 0.001). The readability of the consent form was 40.5 using the FRES and 10.9 using the SMOG index, indicating a university undergraduate level of reading.

Conclusions

This study has shown poor compliance in documenting risks of surgery during the informed consent process in an acute trauma setting compared to elective arthroplasty. Institutions must prioritize improving documentation of informed consent for orthopaedic trauma patients to ensure a patient‐centred approach to healthcare.

A survey of specialty choice among obstetrics and gynecology residents in Japan, Korea, and Taiwan

AIM

The percentage of medicine graduates opting for residency in obstetrics and gynecology (OB/GYN) has been decreasing in developed countries, including in Taiwan, Japan, and Korea. This multicountry study surveyed the OB/GYN residents affiliated with the Taiwan Association of Obstetrics and Gynecology (TAOG), the Japanese Society of Obstetrics and Gynecology (JSOG), and the Korean Society of Obstetrics and Gynecology (KSOG) to evaluate the factors affecting the choice of pursing OB/GYN.

METHODS

A 17-item questionnaire surveying the factors influencing the choice of pursuing a major medical specialty was translated into Japanese, Korean, and Chinese and administered to postgraduate OB/GYN residents between July 1, 2020, and August 31, 2020. Data on the participants' sex, age, and level of residency were collected. Responses were compared between countries and sexes.

RESULTS

Residents of all three countries chose OB/GYN based on personal interest, and a sense of accomplishment in saving people's life. Other positive factors include improved quality of life; higher salaries; and more opportunity for new techniques, research, and promotion. The negative factors included medical litigations, longer work hours, and unsafe working environments. Korean residents had lower ratings in several items, including "support from family," "safety of working environment," and "effectiveness of the alternative dispute resolution system," which, unlike Japan and Taiwan, is not a no-fault compensation system for childbirth accidents.

CONCLUSIONS

The study findings can guide strategy making, such as decreasing workload and yet maintain training quality, to increase the number of medical students pursuing OB/GYN residency.

Physician Risk Perception and Testing Behaviors for Children With Fever

OBJECTIVES

Risk tolerance and risk perceptions may impact clinicians' decisions to obtain diagnostic tests. We sought to determine whether physician risk perception was associated with the decision to obtain blood or imaging tests among children who present to the emergency department with fever.

METHODS

We conducted a retrospective, cross-sectional study in the Boston Children's Hospital emergency department. We included children aged 6 months to 18 years from May 1, 2014 to April 30, 2019, with fever. Our primary outcome was diagnostic testing: obtaining a blood and/or imaging test. We assessed risk perception using 3 scales: the Risk Tolerance Scale (RTS), Stress From Uncertainty Scale (SUS), and Malpractice Fear Scale (MFS). A z score was assigned to each physician for each scale. Mixed-effects logistic regression assessed the association between physician risk perception and blood or imaging testing. We also examined the relationship between each risk perception scale and several secondary outcomes: blood testing, urine testing, diagnostic imaging, specialist consultation, hospitalization, and revisit within 72 hours.

RESULTS

The response rate was 55/56 (98%). We analyzed 12,527 encounters. Blood/imaging testing varied between physicians (median, 48%; interquartile range, 41%-53%; range, 30%-71%). Risk Tolerance Scale responses were not associated with blood/imaging testing (odds ratio [OR], 1.03 per SD of increased risk perception; 95% confidence interval [CI], 0.95-1.13). Stress From Uncertainty Scale responses were not associated with blood/imaging testing (OR, 1.04 per SD; 95% CI, 0.95-1.14). Malpractice Fear Scale responses were not associated with blood/imaging testing (OR, 1.00 per SD; 95% CI, 0.91-1.09). There was no significant association between RTS, MFS, or SUS and any secondary outcome, except that there was a weak association between SUS and specialist consultation (OR, 1.12; 95% CI, 1.00-1.24).

CONCLUSIONS

Across 55 pediatric emergency physicians with variable testing practices, there was no association between risk perception and blood/imaging testing in febrile children.

Litigability and defensibility in neurology and neurosurgery. A "therapeutic" model for handling claims for malpractice care

Despite its indisputable importance, there are not many official data on claims for malpractice at the national level in Spain, mainly due to transfers from Health to the Autonomous Communities. This lack of unified information, together with other variables related to modern Healthcare Medicine (type of healthcare system, ethical aspects, consent, patients' rights, new technologies, etc.), complicates the healthcare professional's response to claims, and could not guarantee adequate protection of this against possible liability. This article analyzes the current situation in Spain and emphasizes aspects such as defensibility and liability in malpractice claims, taking as a model the Neurosurgery Specialty, one of the most prone to this type of situation. Prevention and action guidelines are offered, through a model aimed at reinforcing defensibility and reducing liability. This approach, which we call a "therapeutic model", considers the problem analogously to a disease, providing the basis for its prevention and management. We believe that this approach can be useful both to the Neurosurgeon and to any healthcare provider at a time, such as today, when there is some confusion on these issues and some reluctance of insurance companies to provide coverage in some cases.

Technology-Based Closed-Loop Tracking for Improving Communication and Follow-up of Pathology Results

OBJECTIVE

Failure to follow-up on laboratory test results can lead to missed diagnoses, diagnostic delays, patient harm, and potential malpractice claims against providers. State-of-the-art tracking technologies such as the radio frequency identification (RFID) can potentially improve laboratory order processing and test result communication. We conducted a comparative evaluation of differences in completion rates for 5 testing process milestones and time to reach these process milestones, with and without RFID order tracking for skin biopsy orders.

METHODS

This observational study analyzed 48,515 orders from 20 dermatology providers, sent to 8 pathology laboratories in 2016 to 2017. Descriptive t tests and multiple Cox proportional hazard regressions were used to examine the differences in completion rates and times to the 5 testing process milestones, namely, (1) provider receipt of results, (2) provider review of results, (3) patient notification, (4) follow-up scheduling, and (5) order case closure, for orders processed with and without RFID order tracking.

RESULTS

Descriptive statistics illustrated that all 5 testing process milestone completion rates were statistically higher for RFID tracked orders compared with non-RFID tracked orders, and RFID tracked orders took 3 to 5 days lesser than non-RFID tracked orders to reach the 5 testing process milestones. Multiple cox proportional hazard regressions showed that the process milestones were achieved faster if orders were RFID tracked versus not (hazard ratios ranged from 1.3 to 4.9).

CONCLUSIONS

The RFID tracking technology considerably improved test result communication timeliness and reliability. Such technologies can be beneficial for laboratory order processing, and their effectiveness should be explored in other practice settings.

Current Trends and Predictors of Case Outcomes for Malpractice in Colonoscopy in the United States

BACKGROUND

Over 14 million colonoscopies are performed annually, and this procedure remains the largest contributor to malpractice claims against gastroenterologists. The aim of this study was to evaluate reasons for litigation and predictors of case outcomes.

MATERIALS AND METHODS

Cases related to colonoscopy were reviewed within the Westlaw legal database. Patient demographics, reasons for litigation, case payouts, and verdicts were assessed. Multivariate regression was used to determine predictors of defendant verdicts.

RESULTS

A total of 305 cases were included from years 1980 to 2017. Average patient age was 54.9 years (range, 4 to 93) and 52.8% of patients were female. Juries returned defendant and plaintiff verdicts in 51.8% and 25.2% of cases, respectively, and median payout was $995,000. Top reasons for litigation included delay in treatment (65.9%) and diagnosis (65.6%), procedural error (44.3%), and failure to refer (25.6%). Gastroenterologists were defendants in 71% of cases, followed by primary care (32.2%) and surgeons (14.8%). Cases citing informed consent predicted defendant verdict (odds ratio, 4.05; 95% confidence interval, 1.90-9.45) while medication error predicted plaintiff verdict (odds ratio, 0.18; 95% confidence interval, 0.04-0.59). Delay in diagnosis (P=0.060) and failure to refer (P=0.074) trended toward plaintiff verdict but did not reach significance. Most represented states were New York (21.0%), California (13.4%), Pennsylvania (13.1%), Massachusetts (12.5%).

CONCLUSIONS

Malpractice related to colonoscopy remains a significant and has geographic variability. Errors related to sedation predicted plaintiff verdict and may represent a target to reduce litigation. Primary care physicians and surgeons were frequently cited codefendants, underscoring the significance of interdisciplinary care for colonoscopy.

The Morbidity and Mortality Conference: Opportunities for Enhancing Patient Safety

ABSTRACT

Since the 20th century, health care institutions have used morbidity and mortality conferences (MMCs) as a forum to discuss complicated cases and fatalities to capitalize on lessons learned. Medical technology, health care processes, and the teams who provide care have evolved over time, but the format of the MMC has remained relatively unchanged. The present article outlines 5 key areas for improvement within the MMC along with prescriptive and actionable recommendations for mitigating these challenges. This work incorporates the contributions of numerous researchers and practitioners from the educational, training, debrief, and health care fields. With the best practices and lessons learned from various domains in mind, we recommend optimizing the MMC by (1) encouraging a culture that leverages expertise from multiple sources, (2) allocating ample time for innovative thinking, (3) using a global approach that considers individual, team, and system-level factors, (4) leveraging learnings from errors as well as near misses, and (5) promoting communication, innovative thinking, and actionable planning. The 5 evidence-based recommendations herein serve to ensure that MMCs are structured learning events that promote, encourage, and support safe, reliable care. Furthermore, the outlined recommendations seek to capitalize upon the MMC's opportunity to engage early discovery as well as proactive risk assessment and action-oriented solutions.

The prevalence of medical violation claims and associated predictors at the Eastern Province in Saudi Arabia: A logistic regression analysis

Despite efforts to improve healthcare delivery and ensure patient safety, medicolegal claims in Saudi Arabia remain a concerning issue. This study investigated medical violation claims referred to the medical violation committee in the Eastern Province in Saudi Arabia. A retrospective study was conducted on medical violation claims from 2016 to 2019. Binary logistic regression was performed to examine the association between issued verdicts and a set of defendant, plaintiff and healthcare institution variables. During the study's period, the medical violation committee reached final verdicts against 1242 healthcare professionals in which 69% of them were found guilty. The majority of the defendants worked in private healthcare institutions (66%), were physicians (30%), male (53%), and non-Saudi (64%). Working at pharmacies, other healthcare settings, and the private sector were significantly associated with receiving a guilty verdict. Male healthcare professionals as well as pharmacists were found to have a higher likelihood to receive a guilty verdict than their respective counterparts. Medical violation claims filled by the Ministry of Health were more likely to receive guilty verdicts than those filled by patients or healthcare professionals. Findings of the study extend the literature on medicolegal claims and introduces implications for healthcare professionals and policymakers at institutional and national levels.

The challenge of competency assessment of the late-career practitioner

Just as the general population of the United States is aging, so, too, is the population of active physicians. Training to become a physician and practice medicine is an arduous process. The competition to gain admission to medical school is fierce, the price tag of medical education is high, and waiting to learn about matching to a residency program is stressful. No wonder that physicians equate their profession with their identity. This sentiment, along with other factors, has resulted in many physicians continuing to practice well beyond the average retirement age. While each individual ages differently, there is evidence that the aging of physicians and length of time since medical school and residency is associated with deficiencies in history-taking, physical examination, record-keeping, and the ability to problem-solve. For late-career surgeons performing complex surgical procedures, there is a higher mortality rate for patients. Unlike other professions that have a mandatory retirement age, medicine does not. Health systems are grappling with how to fairly assess the competence of late-career practitioners. This article will explore that challenge from different perspectives, identify best practices, and describe how a risk manager can facilitate stakeholder discussion focused on implementing a competency-assessment process that is fair and effective.

The Effect of Clinical Volume on Annual and Per-Patient Encounter Medical Malpractice Claims Risk

OBJECTIVES

The relationship between medical malpractice risk and one of the fundamental characteristics of physician practice, clinical volume, remains undefined. This study examined how the annual and per-patient encounter medical malpractice claims risk varies with clinical volume.

METHODS

Clinical volume was determined using health insurance charges and was linked at the physician level to malpractice claims data from a malpractice insurer. The annual medical malpractice claims risk was expressed as the percent of physicians with a malpractice claim, and the per-encounter medical malpractice claims risk was expressed as malpractice claims per 1000 patient encounters. Both of these malpractice claims risk metrics were analyzed as a function of clinical volume, using linear and spline regression.

RESULTS

As clinical volume increased, the percent of physicians with a malpractice claim increased linearly. Among all physicians studied, for each decile increase in clinical volume, there was a 0.373% increase in physicians with a malpractice claim (95% confidence interval, 0.301%-0.446%; P < 0.0001). As clinical volume increased, the rate of malpractice claims per 1000 patient encounters decreased. This relationship between clinical volume and per-encounter claims risk was nonlinear. There was a clinical volume threshold, below which decreasing clinical volume was associated with increasing per-encounter claims risk, and above which claims risk no longer significantly varied with increases in clinical volume.

CONCLUSIONS

Clinical volume is a crucial determinant of physician malpractice risk, with higher-volume physicians having higher annual risk but lower per-encounter risk. Clinical volume data should be incorporated into analyses of malpractice risk.

Malpractice Woes: Here Is What You Should Do if You Get Sued

This article relates the first-hand experience of a surgeon who faced 2 medical malpractice actions separated by 30 years and how each of those experiences affected him. The first episode occurred early in his career and caused anxiety, fear, and anger. The importance of getting support during a medical malpractice event, and the opportunities to do so, are discussed. The timeline of a typical medical malpractice lawsuit and phases of the litigation process are detailed. The authors provide guidance on how to make this process less stressful. The article summarizes medical malpractice lawsuits involving otolaryngologists.

Organisational determinants and consequences of diagnostic discrepancy in two large patient groups in the emergency departments: a national study of consecutive episodes between 2008 and 2016

Background

Diagnostic discrepancy (DD) is a common phenomenon in healthcare, but little is known about its organisational determinants and consequences. Thus, the aim of the study was to evaluate this among selected emergency department (ED) patients.

Method

We conducted an observational study including all consecutive ED patients (hip fracture or erysipelas) in the Danish healthcare sector admitted between 2008 and 2016. DD was defined as a discrepancy between discharge and admission diagnoses. Episode and department statistics were retrieved from Danish registers. We conducted a survey among all 21 Danish EDs to gather information about organisational determinants. To estimate the results while adjusting for episode- and department-level heterogeneity, we used mixed effect models of ED organisational determinants and 30-day readmission, 30-day mortality and episode costs (2018-DKK) of DDs.

Results

DD was observed in 2308 (3.3%) of 69,928 hip fracture episodes and 3206 (8.5%) of 37,558 erysipelas episodes. The main organisational determinant of DD was senior physicians (nonspecific medical specialty) being employed at the ED (hip fracture: odds ratio (OR) 2.74, 95% confidence interval (CI) 2.15–3.51; erysipelas: OR 3.29, 95% CI 2.65–4.07). However, 24-h presence of senior physicians (nonspecific medical specialty) (hip fracture) and availability of external senior physicians (specific medical specialty) (both groups) were negatively associated with DD. DD was associated with increased 30-day readmission (hip fracture, mean 9.45% vs 13.76%, OR 1.46, 95% CI 1.28–1.66, p < 0.001) and episode costs (hip fracture, 61,681 DKK vs 109,860 DKK, log cost 0.58, 95% CI 0.53–0.63, p < 0.001; erysipelas, mean 20,818 DKK vs 56,329 DKK, log cost 0.97, 95% CI 0.92–1.02, p < 0.001) compared with episodes without DD.

Conclusion

DD was found to have a negative impact on two out of three study outcomes, and particular organisational characteristics seem to be associated with DD. Yet, the complexity of organisations and settings warrant further studies into these associations.

Automated identification of diagnostic labelling errors in medicine

Objectives

Identification of diagnostic error is complex and mostly relies on expert ratings, a severely limited procedure. We developed a system that allows to automatically identify diagnostic labelling error from diagnoses coded according to the international classification of diseases (ICD), often available as routine health care data.

Methods

The system developed (index test) was validated against rater based classifications taken from three previous studies of diagnostic labeling error (reference standard). The system compares pairs of diagnoses through calculation of their distance within the ICD taxonomy. Calculation is based on four different algorithms. To assess the concordance between index test and reference standard, we calculated the area under the receiver operating characteristics curve (AUROC) and corresponding confidence intervals. Analysis were conducted overall and separately per algorithm and type of available dataset.

Results

Diagnoses of 1,127 cases were analyzed. Raters previously classified 24.58% of cases as diagnostic labelling errors (ranging from 12.3 to 87.2% in the three datasets). AUROC ranged between 0.821 and 0.837 overall, depending on the algorithm used to calculate the index test (95% CIs ranging from 0.8 to 0.86). Analyzed per type of dataset separately, the highest AUROC was 0.924 (95% CI 0.887–0.962).

Conclusions

The trigger system to automatically identify diagnostic labeling error from routine health care data performs excellent, and is unaffected by the reference standards’ limitations. It is however only applicable to cases with pairs of diagnoses, of which one must be more accurate or otherwise superior than the other, reflecting a prevalent definition of a diagnostic labeling error.

Malpractice Claims of Internal Medicine Involving Diagnostic and System Errors in Japan

Objectives Medical litigation resulting from diagnostic errors leads to lawsuits that are time-consuming, expensive, and psychologically burdensome. Few studies have focused on internists, who are more likely to make diagnostic errors than others, with assessments of litigation in terms of system and diagnostic errors. This study explored factors contributing to internists losing lawsuits and examined whether system or diagnostic errors were more important on the outcome. Methods Data regarding 419 lawsuits against internists closed between 1961 and 2017 were extracted from a public Japanese database. Factors affecting litigation outcomes were identified by comparative analysis focusing on system and diagnostic errors, environmental factors, and differences in initial diagnoses. Results Overall, 419 malpractice claims against internists were analyzed. The rate of lawsuits being decided against internists was high (50.1%). The primary cause of litigation was diagnostic errors (213, 54%), followed by system errors (188, 45%). The foremost initial diagnostic error was "no abnormality" (17.2%) followed by ischemic heart disease (9.6%) and malignant neoplasm (8.1%). Following cause-adjustment for loss, system errors were 21.37 times more likely to lead to a loss. Losses were 6.26 times higher for diagnostic error cases, 2.49 times higher for errors occurring at night, and 3.44 times higher when "malignant neoplasm" was the first diagnosis. Conclusions This study found that system errors strongly contributed to internists' losses. Diagnostic errors, night shifts, and initial diagnoses of malignant neoplasms also significantly affected trial outcomes. Administrators must focus on both system errors and diagnostic errors to enhance the safety of patients and reduce internists' risk exposure.

Malpractice Allegations Against Vascular Surgeons:Prevalence, Risk Factors, and Impact on Surgeon Wellness

OBJECTIVES

The contemporary medicolegal environment has been linked to procedure overuse, healthcare variation, and higher costs. For physicians accused of malpractice, there is also a personal toll. The objective of this study was to evaluate the prevalence of and risk factors for involvement in medical malpractice lawsuits among US vascular surgeons, and to examine the association between these allegations with surgeon wellness.

METHODS

In 2018, the Society of Vascular Surgery (SVS) Wellness Task Force conducted a confidential survey of active members using a validated burnout assessment (Maslach Burnout Index) embedded into a questionnaire. This survey included questions related to medical errors and malpractice litigation. De-identified demographic, personal, and practice-related characteristics were assessed in respondents who reported malpractice allegations in the preceding two years, then compared to those without recent medicolegal litigation. Risk factors for malpractice allegations were identified (chi-square, Kruskal-Wallis tests), and the association between malpractice allegations with wellness was examined. Multivariate logistic regression models were developed to identify independent risk factors for malpractice accusations.

RESULTS

Of 2905 active SVS members, 871 responses from practicing vascular surgeons were analyzed. 161 (18.5%) were named in a malpractice lawsuit within two years. Malpractice allegations were significantly associated with surgeon burnout [OR 1.47 (1.01, 2.15), p=0.041], but not with self-reported depression or suicidal ideation. The nature of malpractice claims included procedural errors (23.1%), failure to treat (18.8%) and error/delay in diagnosis (16.9%). 20% of claims were settled prior to trial and 19% were dismissed. Defendant vascular surgeons reported a "fair" resolution in 26.4% of closed cases. By unadjusted analysis, factors significantly associated with recent malpractice claims included mean age (51.7+/-10.0 vs. 49.3+/-11.2; p=0.0044) and mean years in practice (18.0+/-10.7 vs. 15.2+/-11.8; p=0.0007). Multivariate analysis revealed independent variables associated with malpractice allegations, including on-call frequency (p=0.0178), recent medical errors (p=0.0189), and male surgeons (p=0.045).

CONCLUSIONS

Malpractice allegations are common for vascular surgeons and are significantly associated with surgeon burnout. Nearly 20% of survey respondents reported being named in a lawsuit within the preceding two years. Our findings underscore the need for SVS initiatives to provide counseling and peer support for vascular surgeons facing litigation.

A Retrospective Analysis of Malpractice-Related Procedure Rates for Internal Medicine Specialists at an Academic Medical Center

BACKGROUND

Although malpractice litigation is common in the United States, the risk of a malpractice claim for procedures performed by internal medical practitioners is unknown. This study determined the frequency of malpractice claims related to procedures in a large department of medicine at an academic medical center over a five-year period.

METHODS

Researchers retrospectively reviewed all malpractice claims and procedures performed by internal medicine practitioners of all specialties between July 1, 2014, and June 30, 2019, in a department of medicine at a large academic medical center. A list of all procedures and Current Procedural Terminology codes performed by internal medicine practitioners was compiled. Active procedure-related malpractice claims and the total number of procedures performed during the study period were counted.

RESULTS

During the study period, 353,661 procedures were performed by internal medicine practitioners. During the same period, 76 active malpractice claims were identified, of which only 13 (17.1%) were procedure-related. For 2 different malpractice claims, a single patient had 2 procedures; thus 13 total claims related to the performance of 15 procedures. The proportion of procedure-related claims per total number of procedures performed was 0.37 claims/10,000 cases. The frequency of procedure-related malpractice claims per number of procedures performed ranged from 1 in 38 for pulmonary artery thrombolytic therapy to 1 in 137,325 for colonoscopy.

CONCLUSION

Procedure-related malpractice claims against internal medicine practitioners at a large academic medical center over a five-year period were infrequent despite significant procedural volume. Contextualizing procedure-related malpractice claims in terms of procedure-specific volume reframes the reporting of malpractice risk.

nalyzing diagnostic errors in the acute setting: a process-driven approach

OBJECTIVES

We describe an approach for analyzing failures in diagnostic processes in a small, enriched cohort of general medicine patients who expired during hospitalization and experienced medical error. Our objective was to delineate a systematic strategy for identifying frequent and significant failures in the diagnostic process to inform strategies for preventing adverse events due to diagnostic error.

METHODS

Two clinicians independently reviewed detailed records of purposively sampled cases identified from established institutional case review forums and assessed the likelihood of diagnostic error using the Safer Dx instrument. Each reviewer used the modified Diagnostic Error Evaluation and Research (DEER) taxonomy, revised for acute care (41 possible failure points across six process dimensions), to characterize the frequency of failure points (FPs) and significant FPs in the diagnostic process.

RESULTS

Of 166 cases with medical error, 16 were sampled: 13 (81.3%) had one or more diagnostic error(s), and a total of 113 FPs and 30 significant FPs were identified. A majority of significant FPs (63.3%) occurred in "Diagnostic Information and Patient Follow-up" and "Patient and Provider Encounter and Initial Assessment" process dimensions. Fourteen (87.5%) cases had a significant FP in at least one of these dimensions.

CONCLUSIONS

Failures in the diagnostic process occurred across multiple dimensions in our purposively sampled cohort. A systematic analytic approach incorporating the modified DEER taxonomy, revised for acute care, offered critical insights into key failures in the diagnostic process that could serve as potential targets for preventative interventions.