Risk management in suspected acute appendicitis

[Malpractice claims relating to the diagnosis and treatment of acute appendicitis--decisions of the Norddeutsche Schlichtungsstelle (Expert Panel for Extrajudicial Claims Resolution of the Medical Associations in Northern Germany)]

During the five years between 2000 and 2004 the Norddeutsche Schlichtungsstelle decided on 241 malpractice claims relating to the diagnosis and treatment of acute appendicitis including 220 hospitals and 60 primary care outpatient facilities. 29 claims involved two and 5 claims involved three physicians/hospitals. One third of the 241 claims were related to non-surgical specialties. The rate of negligent adverse events was 117/241 (49%); surgeons accounted for 41% of the claims, and non-surgeons for 67%; 46% of the claims involved hospitals, and 65% outpatient facilities. There were 127/241 (53%) cases of perforated appendicitis; and in 90% of these cases the patients complained of delayed diagnosis and/or operation. In the 114/241 (47%) cases with non-perforated appendicitis patients complained of errors related to operative procedures, of delayed re-interventions and of non-surgical complications. The degree of disability was determined in all cases of iatrogenic injury due to medical negligence: the impairment was transient and minimal to moderate in 67 of injured patients; transient and serious in 35, permanent and serious impairment in 12 cases, and 3 patients died (another 2 cases of deaths were unrelated to negligence or iatrogenic injury). Outstanding errors documented in these cases of appendicitis included: failure to conduct a follow-up examination within 12-24 hours; delayed re-intervention for peritonitis or peritoneal abscess. Puncture lesions of the bowel or great vessels due to iatrogenic injury acquired in the course of laparoscopic appendectomy were reported in 8 cases.

Abdominal surgical emergencies in the elderly

The evaluation of abdominal pain can be considerably more challenging in elderly patients. A higher likelihood of life-threatening pathology combined with a myriad of diagnostic pitfalls in this population mandate a more cautious approach with greater use of diagnostic resources and specialist consultation.