Analysis of Forensic Autopsy in 120 Cases of Medical Disputes Among Different Levels of Institutional Settings

The influence factors of medical disputes in Shanghai and implications - from the perspective of doctor, patient and disease

Objective

This study aimed to explore the causes and factors behind medical disputes that occurred across eight hospitals in Shanghai over a three-year period (January 2018 to December 2020), thus providing targeted suggestions for amelioration.

Methods

Stratified sampling was employed to collect 561 cases in which medical disputes occurred at two tertiary hospitals, two secondary hospitals, and four primary hospitals in Shanghai. The causes were analyzed using descriptive statistics, while the factors affecting the dispute level (i.e., 1 through 4, with 1 being most severe) were analyzed via one-way ANOVA and logistic regression analyses. 

Results

Doctors and patients variously contributed to the medical disputes; 86.1% were related to doctors, while 13.9% were related to patients. For doctors, there are seventeen factors that influenced medical disputes. In particular, the insufficient communication (28.82%) is the most prominent factor in the doctors’ factors. For patients, there are seven factors that influenced medical disputes. In particular, the misunderstanding of medical behavior (43.48%) is the most prominent factor in the patients’ factors. Of all investigated medical disputes, 406 were level 4 (78%), 95 were level 3 (18%), and 19 were level 2 (4%); there were no level 1 disputes. The reasons for different level placements included the disease classification, treatment effect, diagnosis and treatment regulation violations by doctors, and low technical levels.

Conclusions

In addition to strengthening training about clinical and communication skills, the hospitals should establish quality control mechanisms for case records and construct rapid, standardized referral mechanisms. The doctors should attach great importance to the quality and urgency of treatment given to critically ill patients, who must be informed about their prognoses in a timely manner to avoid medical disputes and physical deterioration. The patients should actively cooperate with their doctors in the treatment process, moderate any unrealistic expectations that patients may have about the outcomes. During the COVID-19 pandemic particularly, doctors and patients should strengthen empathy and mutual trust more, then defeat disease together.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08490-5.

Fetal, neonatal, and infant death in central China (Hubei): A 16-year retrospective study of forensic autopsy cases

Data based on forensic autopsy in neonates and infants in China are rare in the literature. The purpose of this study is to evaluate the characteristics of fetal, neonatal, and infant death and to determine the main cause of death among them.A retrospective analysis of fetal and infant forensic autopsies referred to the Tongji Forensic Medical Center (TFMC) in Hubei, central China, during a 16-year period between January 1999 and December 2014, was performed.In this period, there were 1111 males and 543 females; the total male-to-female ratio (MFR) was 2.05:1. There were 173 fetal and infant autopsies conducted, comprised of 43 fetal, 84 neonatal (<28 days) and 46 infant (4 weeks to 1 year) cases. The annual case number ranged from 5 in 2004 to 18 in 2014 (annual mean of 10.8). MFR was 1.75:1. About 94% of these deaths (163/173) resulted from natural causes, 6 cases (3.5%) were accidental deaths, and 4 (2.3%) resulted from homicide (4 abandoned babies). Among fetuses, the most common causes of death were placental and umbilical cord pathologies (28%, 12/43), followed by intrapartum asphyxia resulting from amniotic fluid aspiration (AFA) or meconium aspiration syndrome (MAS) (18.6%, 8/43), congenital malformation (14%, 6/43), and intrapartum infection (9.3%, 4/43). A majority of neonatal deaths (66.7%, 56/84) died within 24 hours of birth. The main causes of neonatal death were asphyxia resulting from AFA, MAS, or hyaline membrane disease, and congenital malformation. The main causes of infant (1-12 months) death were infectious diseases, including pneumonia, meningitis, and viral brainstem encephalitis.This study was the 1st retrospective analysis of autopsies of fetal, neonatal, and infant death in TFMC and central China. We delineate the common causes of early demise among cases referred for autopsy, and report a male preponderance in this population. Our data observed that placental and/or umbilical cord pathology, asphyxia due to AFA, and/or MAS, and pneumonia were the leading causes of fetal, neonatal, and infant death, respectively. And it can inform clinical practitioners about the underlying causes of some of the most distressing cases in their practices.

Diagnostic errors in fatal medical malpractice cases in Shanghai, China: 1990-2015

Background

Medical disputes remain unabated in China. Previous studies have shown the changes of diagnostic discrepancy over time in developed countries, but diagnostic discrepancy remains understudied in China, especially in the setting of medical disputes. We sought to describe the year-based changes of diagnostic discrepancies in medical disputes, and to identify factors associated with classes of diagnostic discrepancy.

Methods

We conducted a retrospective cohort study of all medically disputed cases from 1990 through 2015 in Shanghai, China, with use of necropsy as the gold standard for diagnosis. Cases were grouped based on national legislative eras. Diagnostic discrepancy was classified as major errors (class I and II), minor errors (class III and IV), no discrepancy (class V) and undetermined (class VI) based on discrepancy severity.

Results

There were 482 medical disputes. Cases were predominantly males (male: female = 1.6:1) and concentrated in patients less than 10 years old or between 50 and 70 years. Major and minor discrepancy accounted for 51.7 and 34.8%, respectively. Fifty-five cases (11.2%) were non-discrepant (Class V). The dispute rate remained high before the first round of legislation (mean 0.31 per 1 million patients) but declined dramatically afterwards (R² = − 0.82, p < 0.001 for time trends). Over the national legislative eras, the annual number of cases with diagnostic errors declined steadily. Incidence rates of discrepancy decreased significantly for class I (R² = − 0.73, p = 0.024), II (R² = − 0.48, p = 0.013), III (R² = − 0.69, p < 0.0001), IV (R² = − 0.69, p < 0.0001) and V discrepancy (R² = − 0.58, p = 0.0018). Diseases from the respiratory system had significantly lower risks of any diagnostic errors (OR = 0.48, 95% 0.24–0.95, p = 0.036). A neoplasm carrier increased by 92% the risk of any diagnostic error (OR = 1.92; 95%CI 1.18–3.14; p = 0.009) and hypertension reduced by 78% the risk of minor errors (OR = 0.22, 95%CI 0.06–0.91, p = 0.036). Severity of discrepancy relieved over years and associated with ageing in patients with cardiovascular diseases (p = 0.01).

Conclusions

The rate of fatal medical disputes and diagnostic discrepancy declined after stepwise legislations in China. Respiratory diseases, neoplasm carrier and hypertension could be independent predictors for assessing diagnostic errors.