Accountability sought by patients following adverse events from medical care: the New Zealand experience

To find fault is easy, to find no-fault is fair

The inequity of medical negligence-based adversarial litigation in the USA, UK and Australia is a recognised target for reform. Plaintiff autonomy is weakened by a dispute resolution system that has evolved around lawyers, opposed experts and indemnity insurers; the need to prove breach and causation excludes compensation for other categories of medical injury; and patient access to the system is restricted by high entry costs. Two strategies towards reform are raised here. A short-term approach involves routine initial use of a single court-appointed medical expert for assessment of errors and liabilities, thus improving access while relegating fault-finding to a reserve role. In the longer term, adversarial litigation could be replaced in part by a no-fault compensation scheme - such as in Scandinavia, France and New Zealand - funded by taxation and by re-directed medical indemnity fees. Reforms such as these would be challenging to implement, but are achievable, so it is not premature for relevant bodies to consider a timetable for action.

Personality characteristics associated with satisfaction with healthcare and the wish to complain

BACKGROUND

There is increasing evidence that satisfaction with healthcare and complaint rates vary with patients' socio-demographic characteristics. Likewise, patient personality might influence the perception of health care; however, empirical research has been scarce. The aim of this study was to investigate associations between health care user personality and satisfaction with care and urge to complain.

METHODS

This study is a randomized survey among Danish men aged 45 to 70 years (N = 6,756; 30% response rate) with hypothetical vignettes illustrating different courses of healthcare. Assuming they received the care described in vignettes, participants rated their satisfaction and wish to complain on a five-point Likert scale. Information on personality characteristics was obtained through self-reports using the standardized Big Five Inventory-10 (BFI-10).

RESULTS

In multivariate analyses, we found respondents with higher scores on the agreeableness dimension expressing greater satisfaction with care (Likert difference 0.06, 95% CI 0.04 to 0.07; p < 0.001) and decreased wish to complain (-0.07, 95% CI -0.08 to -0.05; p < 0.001) while high neuroticism scores were associated with less satisfaction (-0.02, 95% CI -0.03 to -0.00, p = 0.012) and an increased wish to complain about healthcare (0.04, 95% CI 0.03 to 0.06, p < 0.001). Interaction analyses could demonstrate no statistically significant interaction between the level of patient involvement in decision making in the scenarios and the effect of personality on respondents' satisfaction and wish to complain. Generally, however, when adjusting for personality, respondents' satisfaction increased (P < 0.001) with greater patient involvement illustrated in case scenarios while the wish to complain decreased (P < 0.001).

CONCLUSION

Our findings suggest low agreeableness and high neuroticism scores are associated with lower patient satisfaction with healthcare and increased wish to complain. Irrespective of personality, however, the wish to complain seems responsive to changes in patient involvement, underscoring the importance of inclusive healthcare communication.

Does greater patient involvement in healthcare decision-making affect malpractice complaints? A large case vignette survey

Background

Although research findings consistently find poor communication about medical procedures to be a key predictor of patient complaints, compensation claims, and malpractice lawsuits (“complaints”), there is insufficient evidence to determine if greater patient involvement could actually affect the inclination to complain.

Objectives

We conducted an experimental case vignette survey that explores whether greater patient involvement in decision-making is likely to influence the intention to complain given different decisions and consequences.

Methods

Randomized, national case vignette survey with various levels of patient involvement, decisions, and outcomes in a representative Danish sample of men. We used prostate specific antigen (PSA) screening in men aged 45 to 70 years as the intervention illustrated in 30 different versions of a mock clinical encounter. Versions differed in the amount of patient involvement, the decision made (PSA test or no PSA test), and the clinical outcomes (no cancer detected, detection of treatable cancer, and detection of non-treatable cancer). We measured respondents’ inclination to complain about care in response to the scenarios on a 5-point Likert scale (from 1: very unlikely to 5: very likely).

Results

The response rate was 30% (6,756 of 22,288). Across all scenarios, the likelihood of complaint increased if the clinical outcome was poor (untreatable cancer). Compared with scenarios that involved shared decision-making (SDM), neutral information, or nudging in favor of screening, the urge to complain increased if the patient was excluded from decision-making or if the doctor had nudged the patient to decline screening (mean Likert differences .12 to .16, p < .001). With neutral involvement or nudging in favor of intervention, the desire to complain depended highly on the decision reached and on the patient’s course. This dependence was smaller with SDM.

Conclusions

Greater patient involvement in decision-making appears to be associated with less intention to complain about health care, with SDM resulting in the greatest reduction in complaint likelihood.

Sociodemographic Representativeness in a Nationwide Web-Based Survey of the View of Men on Involvement in Health Care Decision-Making: Cross-Sectional Questionnaire Study

Background

Being able to generalize research findings to a broader population outside of the study sample is an important goal in surveys on the internet. We conducted a nationwide, cross-sectional, web-based survey with vignettes illustrating different levels of patient involvement to investigate men’s preferences regarding participation in health care decision-making. Following randomization into vignette variants, we distributed the survey among men aged 45 to 70 years through the state-authorized digital mailbox provided by the Danish authorities for secure communication with citizens.

Objective

This study aimed to investigate the sociodemographic representativeness of our sample of men obtained in a nationwide web-based survey using the digital mailbox.

Methods

Response rate estimates were established, and comparisons were made between responders and nonresponders in terms of age profiles (eg, average age) and municipality-level information on sociodemographic characteristics.

Results

Among 22,288 men invited during two waves, a total of 6756 (30.31%) participants responded to the survey. In adjusted analyses, responders’ characteristics mostly resembled those of nonresponders. Response rates, however, were significantly higher in older men (odds ratio [OR] 2.83 for responses among those aged 65-70 years compared with those aged 45-49 years, 95% CI 2.58-3.11; P<.001) and in rural areas (OR 1.10 compared with urban areas, 95% CI 1.03-1.18; P=.005). Furthermore, response rates appeared lower in areas with a higher tax base (OR 0.89 in the highest tertile, 95% CI 0.81-0.98; P=.02).

Conclusions

Overall, the general population of men aged 45 to 70 years was represented very well by the responders to our web-based survey. However, the imbalances identified highlight the importance of supplementing survey findings with studies of the representativeness of other characteristics of the sample like trait and preference features, so that proper statistical corrections can be made in upcoming analyses of survey responses whenever needed.

Families of victims of homicide: qualitative study of their experiences with mental health inquiries

BACKGROUND

Investigations may be undertaken into mental healthcare related homicides to ascertain if lessons can be learned to prevent the chance of recurrence. Families of victims are variably involved in serious incident reviews. Their perspectives on the inquiry process have rarely been studied.

AIMS

To explore the experiences of investigative processes from the perspectives of family members of homicide victims killed by a mental health patient to better inform the process of conducting inquiries.

METHOD

The study design was informed by interpretive description methodology. Semi-structured interviews were conducted with five families whose loved one had been killed by a mental health patient and where there had been a subsequent inquiry process in New Zealand. Data were analysed using an inductive approach.

RESULTS

Families in this study felt excluded, marginalised and disempowered by mental health inquires. The data highlight these families' perspectives, particularly on the importance of a clear process of inquiry, and of actions by healthcare providers that indicate restorative intent.

CONCLUSIONS

Families in this study were united in reporting that they felt excluded from mental health inquiries. We suggest that the inclusion of families' perspectives should be a key consideration in the conduct of mental health inquiries. There may be benefit from inquiries that communicate a clear process of investigation that reflects restorative intent, acknowledges victims, provides appropriate apologies and gives families opportunities to contribute.

Learning from complaints in healthcare: a realist review of academic literature, policy evidence and front-line insights

Introduction

A global rise in patient complaints has been accompanied by growing research to effectively analyse complaints for safer, more patient-centric care. Most patients and families complain to improve the quality of healthcare, yet progress has been complicated by a system primarily designed for case-by-case complaint handling.

Aim

To understand how to effectively integrate patient-centric complaint handling with quality monitoring and improvement.

Method

Literature screening and patient codesign shaped the review’s aim in the first stage of this three-stage review. Ten sources were searched including academic databases and policy archives. In the second stage, 13 front-line experts were interviewed to develop initial practice-based programme theory. In the third stage, evidence identified in the first stage was appraised based on rigour and relevance, and selected to refine programme theory focusing on what works, why and under what circumstances.

Results

A total of 74 academic and 10 policy sources were included. The review identified 12 mechanisms to achieve: patient-centric complaint handling and system-wide quality improvement. The complaint handling pathway includes (1) access of information; (2) collaboration with support and advocacy services; (3) staff attitude and signposting; (4) bespoke responding; and (5) public accountability. The improvement pathway includes (6) a reliable coding taxonomy; (7) standardised training and guidelines; (8) a centralised informatics system; (9) appropriate data sampling; (10) mixed-methods spotlight analysis; (11) board priorities and leadership; and (12) just culture.

Discussion

If healthcare settings are better supported to report, analyse and use complaints data in a standardised manner, complaints could impact on care quality in important ways. This review has established a range of evidence-based, short-term recommendations to achieve this.

Medical Malpractice Primer for Practicing Interventional Radiologists

Medical professional liability (MPL), also commonly referred to as medical malpractice, is a costly issue in health care today, accounting for roughly 2.4% of total health care expenditure in the United States. Almost all physicians currently in clinical practice will either be subject to a lawsuit themselves or work with someone who has. Given a lack of formal structured education about MPL in medicine for trainees, this review aims to define and discuss the relevant concepts in MPL as a reference for early career interventionalists to understand the current medicolegal environment and learn best practices to avoid litigation.

Medical malpractice cases in Hippocratic collection: a review and today's perspective

AIM

The aim of the present paper is two-fold. First, it reviews the Hippocratic collection to identify instances related to the issue of medical malpractice and medical negligence. Second, it discusses the results viewed from today's perspective, in the context of contemporary theories of liability in malpractice cases.

METHOD

A careful review of the books of Hippocratic collection was performed, as well as a narrative review of the currently available academic literature, focusing on topics of contemporary theories of liability in malpractice cases, which correspond roughly to the medical malpractice instances identified in Hippocratic collection.

RESULTS

The Hippocratic authors touch on some issues which are essential to the contemporary theory of medical error and negligence, which, however, cannot yet unquestionably address these issues. Among others, they refer to errors that contemporarily might be viewed as technical human errors, errors of omission, or errors which were unavoidable in the context of applied ancient Greek medicine as is the case of injuries that are not based on physician's fault, or situations where the diagnosis of the particular disease or causal link between the physician's breach of duty and the damage suffered, was difficult or even impossible. Interestingly, the Hippocratic authors underscore some errors which might not be based on physician's fault.

CONCLUSION

The passages mentioned in this paper, originating from the Hippocratic collection that refer to medical malpractice, imply an awareness of what is currently discussed as medical malpractice. This consideration may carry some weight, in particular when adopting a flexible traditionalist approach to the medical liability rules. HIPPOKRATIA 2019, 23(3): 99-105.

Malpractice litigation, workload, and general practitioner retirement

We investigated the association between general practitioner (GP) stress factors, including involvement in malpractice litigation or high workload levels during 2007 and ensuing retirement in a sample of Danish GPs. The case file and register information of 739 GPs were examined. Hazard ratios (HRs) were estimated for all causes of retirement from 2007 to 2016. During the study period, 34% of GPs had ceased to practice (n = 260). The HR for retirement was higher with increasing age (HR = 1.19 per year) and lower if practicing in a clinic with a greater number of GPs (HR = 0.47) but no statistically significant association was found between retirement and litigation or higher workload. Knowledge on factors influencing GPs' decision on whether to continue working is important to ensure sustainable primary care provision.

Patient and public involvement in medical performance processes: A systematic review

Background

Patient and public involvement (PPI) continues to develop as a central policy agenda in health care. The patient voice is seen as relevant, informative and can drive service improvement. However, critical exploration of PPI's role within monitoring and informing medical performance processes remains limited.

Objective

To explore and evaluate the contribution of PPI in medical performance processes to understand its extent, purpose and process.

Search strategy

The electronic databases PubMed, PsycINFO and Google Scholar were systematically searched for studies published between 2004 and 2018.

Inclusion criteria

Studies involving doctors and patients and all forms of patient input (eg, patient feedback) associated with medical performance were included.

Data extraction and synthesis

Using an inductive approach to analysis and synthesis, a coding framework was developed which was structured around three key themes: issues that shape PPI in medical performance processes; mechanisms for PPI; and the potential impacts of PPI on medical performance processes.

Main results

From 4772 studies, 48 articles (from 10 countries) met the inclusion criteria. Findings suggest that the extent of PPI in medical performance processes globally is highly variable and is primarily achieved through providing patient feedback or complaints. The emerging evidence suggests that PPI can encourage improvements in the quality of patient care, enable professional development and promote professionalism.

Discussion and conclusions

Developing more innovative methods of PPI beyond patient feedback and complaints may help revolutionize the practice of PPI into a collaborative partnership, facilitating the development of proactive relationships between the medical profession, patients and the public.

Patient-Centered Insights: Using Health Care Complaints to Reveal Hot Spots and Blind Spots in Quality and Safety

Policy Points: Health care complaints contain valuable data on quality and safety; however, there is no reliable method of analysis to unlock their potential. We demonstrate a method to analyze health care complaints that provides reliable insights on hot spots (where harm and near misses occur) and blind spots (before admissions, after discharge, systemic and low-level problems, and errors of omission). Systematic analysis of health care complaints can improve quality and safety by providing patient-centered insights that localize issues and shed light on difficult-to-monitor problems.

CONTEXT

The use of health care complaints to improve quality and safety has been limited by a lack of reliable analysis tools and uncertainty about the insights that can be obtained. The Healthcare Complaints Analysis Tool, which we developed, was used to analyze a benchmark national data set, conceptualize a systematic analysis, and identify the added value of complaint data.

METHODS

We analyzed 1,110 health care complaints from across England. "Hot spots" were identified by mapping reported harm and near misses onto stages of care and underlying problems. "Blind spots" concerning difficult-to-monitor aspects of care were analyzed by examining access and discharge problems, systemic problems, and errors of omission.

FINDINGS

The tool showed moderate to excellent reliability. There were 1.87 problems per complaint (32% clinical, 32% relationships, and 34% management). Twenty-three percent of problems entailed major or catastrophic harm, with significant regional variation (17%-31%). Hot spots of serious harm were safety problems during examination, quality problems on the ward, and institutional problems during admission and discharge. Near misses occurred at all stages of care, with patients and family members often being involved in error detection and recovery. Complaints shed light on 3 blind spots: (1) problems arising when entering and exiting the health care system; (2) systemic failures pertaining to multiple distributed and often low-level problems; and (3) errors of omission, especially failure to acknowledge and listen to patients raising concerns.

CONCLUSIONS

The analysis of health care complaints reveals valuable and uniquely patient-centered insights on quality and safety. Hot spots of harm and near misses provide an alternative data source on adverse events and critical incidents. Analysis of entry-exit, systemic, and omission problems provides insight on blind spots that may otherwise be difficult to monitor. Benchmark data and analysis scripts are downloadable as supplementary files.

The problem with using patient complaints for improvement

'The Problem with…' series covers controversial topics related to efforts to improve healthcare quality, including widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution.

Technical rationality and the decentring of patients and care delivery: A critique of 'unavoidable' in the context of patient harm

In recent decades, debate on the quality and safety of healthcare has been dominated by a measure and manage administrative rationality. More recently, this rationality has been overlaid by ideas from human factors, ergonomics and systems engineering. Little critical attention has been given in the nursing literature to how risk of harm is understood and actioned, or how patients can be subjectified and marginalised through these discourses. The problem of assuring safety for particular patient groups, and the dominance of technical forms of rationality, has seen the word 'unavoidable' used in connection with intractable forms of patient harm. Employing pressure injury policy as an exemplar, and critically reviewing notions of risk and unavoidable harm, we problematise the concept of unavoidable patient harm, highlighting how this dominant safety rationality risks perverse and taken-for-granted assumptions about patients, care processes and the nature of risk and harm. In this orthodoxy, those who specify or measure risk are positioned as having more insight into the nature of risk, compared to those who simply experience risk. Driven almost exclusively as a technical and administrative pursuit, the patient safety agenda risks decentring the focus from patients and patient care.

Clinical Practice Guideline: Safe Medication Use in the ICU

OBJECTIVE

To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill.

DATA SOURCES

PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015.

STUDY SELECTION

Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed.

DATA EXTRACTION

Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation.

DATA SYNTHESIS

The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations.

CONCLUSIONS

This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.

Complications: acknowledging, managing, and coping with human error

Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication. Proper error disclosure includes a timely explanation of what happened, who was involved, why the error occurred, and how it will be prevented in the future. Medical mistakes afford the opportunity for individuals and institutions to be candid about their weaknesses while improving patient care processes. When a physician takes the Hippocratic Oath they take on a tremendous sense of responsibility for the care of their patients, and often bear the burden of their mistakes in isolation. Physicians may struggle with guilt, shame, and a crisis of confidence, which may thwart efforts to identify areas for improvement that can lead to meaningful change. Coping strategies for providers include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. Physicians and health care organizations need to find adaptive ways to deal with complications that will benefit patients, providers, and their institutions.

Disclosing Adverse Events to Patients: International Norms and Trends

OBJECTIVES

There is a growing expectation in health systems around the world that patients will be fully informed when adverse events occur. However, current disclosure practices often fall short of this expectation.

METHODS

We reviewed trends in policy and practice in 5 countries with extensive experience with adverse event disclosure: the United States, the United Kingdom, Canada, New Zealand, and Australia.

RESULTS

We identified 5 themes that reflect key challenges to disclosure: (1) the challenge of putting policy into large-scale practice, (2) the conflict between patient safety theory and patient expectations, (3) the conflict between legal privilege for quality improvement and open disclosure, (4) the challenge of aligning open disclosure with liability compensation, and (5) the challenge of measurement related to disclosure.

CONCLUSIONS

Potential solutions include health worker education coupled with incentives to embed policy into practice, better communication about approaches beyond the punitive, legislation that allows both disclosure to patients and quality improvement protection for institutions, apology protection for providers, comprehensive disclosure programs that include patient compensation, delinking of patient compensation from regulatory scrutiny of disclosing physicians, legal and contractual requirements for disclosure, and better measurement of its occurrence and quality. A longer-term solution involves educating the public and health care workers about patient safety.

Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010-2013 national accident reports

OBJECTIVES

We sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor non-technical skills, and to support development of a policy to reduce number of such accidents by making recommendations about possible training requirements.

DESIGN

Summaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination.

SETTING

A total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013.

PRIMARY AND SECONDARY OUTCOME MEASURES

The cause of death in fatal medical accidents, categorised into technical skills, non-technical skills and inevitable progress of disease were evaluated. Non-technical skills were further subdivided into situation awareness, decision making, communication, team working, leadership, managing stress and coping with fatigue.

RESULTS

Overall, the cause of death was identified as non-technical skills in 34 cases (46.6%), disease progression in 33 cases (45.2%) and technical skills in two cases (5.5%). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified as 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team working and three (8.8%) with decision making. These three subcategories, or combinations of them, were identified as the cause of death in 33 cases (97.1%).

CONCLUSIONS

Poor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for reducing accidents, and training in particular subcategories of non-technical skills may be especially relevant.

Obligation towards medical errors disclosure at a tertiary care hospital in Dubai, UAE

OBJECTIVE: The study aimed to identify healthcare providers’ obligation towards medical errors disclosure as well as to study the association between the severity of the medical error and the intention to disclose the error to the patients and their families.

DESIGN: A cross-sectional study design was followed to identify the magnitude of disclosure among healthcare providers in different departments at a randomly selected tertiary care hospital in Dubai.

SETTING AND PARTICIPANTS: The total sample size accounted for 106 respondents. Data were collected using a questionnaire composed of two sections namely; demographic variables of the respondents and a section which included variables relevant to medical error disclosure.

RESULTS: Statistical analysis yielded significant association between the obligation to disclose medical errors with male healthcare providers (X² = 5.1), and being a physician (X² = 19.3). Obligation towards medical errors disclosure was significantly associated with those healthcare providers who had not committed any medical errors during the past year (X² = 9.8), and any type of medical error regardless the cause, extent of harm (X² = 8.7). Variables included in the binary logistic regression model were; status (Exp β (Physician) = 0.39, 95% CI 0.16–0.97), gender (Exp β (Male) = 4.81, 95% CI 1.84–12.54), and medical errors during the last year (Exp β (None) = 2.11, 95% CI 0.6–2.3).

CONCLUSION: Education and training of physicians about disclosure conversations needs to start as early as medical school. Like the training in other competencies required of physicians, education in communicating about medical errors could help reduce physicians’ apprehension and make them more comfortable with disclosure conversations.

Explaining medical disputes in Chinese public hospitals: the doctor-patient relationship and its implications for health policy reforms

In recent years China has witnessed a surge in medical disputes, including many widely reported violent riots, attacks, and protests in hospitals. This is the result of a confluence of inappropriate incentives in the health system, the consequent distorted behaviors of physicians, mounting social distrust of the medical profession, and institutional failures of the legal framework. The detrimental effects of the damaged doctor-patient relationship have begun to emerge, calling for rigorous study and serious policy intervention. Using a sequential exploratory design, this article seeks to explain medical disputes in Chinese public hospitals with primary data collected from Shenzhen City. The analysis finds that medical disputes of various forms are disturbingly widespread and reveals that inappropriate internal incentives in hospitals and the heavy workload of physicians undermine the quality of clinical encounters, which easily triggers disputes. Empirically, a heavy workload is associated with a larger number of disputes. A greater number of disputes are associated with higher-level hospitals, which can afford larger financial settlements. The resolution of disputes via the legal channel appears to be unpopular. This article argues that restoring a healthy doctor-patient relationship is no less important than other institutional aspects of health care reform.

A insustentável leveza da culpa: a compensação de danos no exercício da medicina

Resumo Diante das crescentes dificuldades apresentadas pela responsabilidade civil para lidar com a má -prática médica e com a compensação aos pacien tes, muitos advogam a implementação do sistema no-fault , isto é, um mecanismo no qual o paciente é compensado por via de um fundo económico de socialização do risco, independentemente da de monstração de negligência por parte do médico. Neste estudo comparámos as principais notas do modelo no-fault com o clássico modelo fundado na culpa, com vista a determinar qual o mais adequa do em termos de justiça, melhoria dos cuidados de saúde e segurança do paciente. Concluímos que, apesar de o modelo no-fault trazer muitas vantagens, também envolve sérias difi culdades, riscos e fragilidades. Nomeadamente, é duvidoso que promova a diligência na prestação de cuidados médicos, dado que em regra não se verifica qualquer sanção para o profissional de saúde. Além disso, só pode operar com sucesso em condições mui to concretas, que não se encontram na maior parte das ordens jurídicas. Por conseguinte, não cremos que seja a solução mais adequada, pelo menos quan do implementada como um mecanismo geral para lidar com danos causados por tratamentos médicos.

Complaint handling in healthcare: expectation gaps between physicians and the public; results of a survey study

BACKGROUND

Patients who submit complaints about the healthcare they have received are often dissatisfied with the response to their complaints. This is usually attributed to the failure of physicians to respond adequately to what complainants want, e.g. an apology or an explanation. However, expectations of complaint handling among the public may colour how they evaluate the way their own complaint is handled. This descriptive study assesses expectations of complaint handling in healthcare among the public and physicians. Negative public expectations and the gap between these expectations and those of physicians may explain patients' dissatisfaction with complaints procedures.

METHODS

We held two surveys; one among physicians, using a panel of 3366 physicians (response rate 57 %, containing all kinds of physicians like GP's, medical specialist and physicians working in a nursing home) and one among the public, using the Dutch Healthcare Consumer Panel (n = 1422, response rate 68 %). We asked both panels identical questions about their expectations of how complaints are handled in healthcare. Differences in expectation scores between the public and the physicians were tested using non-parametric tests.

RESULTS

The public have negative expectations about how complaints are handled. Physician's expectations are far more positive, demonstrating large expectation gaps between physicians and the public.

CONCLUSIONS

The large expectation gap between the public and physicians means that when they meet because of complaint, they are likely to start off with opposite expectations of the situation. This is no favourable condition for a positive outcome of a complaints procedure. The negative public preconceptions about the way their complaint will be handled will prove hard to change during the process of complaints handling. People tend to see what they thought would happen, almost inevitably leading to a negative judgement about how their complaint was handled.

An Experimental Study of Medical Error Explanations: Do Apology, Empathy, Corrective Action, and Compensation Alter Intentions and Attitudes?

Medical malpractice lawsuits are a growing problem in the United States, and there is much controversy regarding how to best address this problem. The medical error disclosure framework suggests that apologizing, expressing empathy, engaging in corrective action, and offering compensation after a medical error may improve the provider-patient relationship and ultimately help reduce the number of medical malpractice lawsuits patients bring to medical providers. This study provides an experimental examination of the medical error disclosure framework and its effect on amount of money requested in a lawsuit, negative intentions, attitudes, and anger toward the provider after a medical error. Results suggest empathy may play a large role in providing positive outcomes after a medical error.

Litigation in English rhinology

Objective:

Litigation is a rising financial burden on the National Health Service. This study aims to show if litigation is increasing in rhinology and which procedures lead to the most claims.

Methods:

Ten years of data were obtained from the National Health Service Litigation Authority. Rhinology claims were examined for cost, injury, diagnosis and operation type.

Results:

Of the 123 rhinology claims identified, 52 per cent were successful. There was a 56 per cent increase in the average annual number of claims between the first half of the study period and the second (p = 0.0451). The commonest reasons for a claim were poor cosmesis (15.6 per cent) and lack of informed consent (14 per cent).

Conclusion:

The number of claims in rhinology increased over the study period. Most claims resulted from poor cosmetic outcome, lack of consent or recognised complications. It is suggested that enhanced communication and management of patient expectations could reduce litigation and improve patient satisfaction.

Regulating healthcare complaints: a literature review

Purpose

– The purpose of this paper is to explore approaches to the regulation of healthcare complaints and disciplinary processes.

Design/methodology/approach

– A literature review was conducted across Medline, Sociological Abstracts, Web of Science, Google Scholar and the health, law and social sciences collections of Informit, using terms tapping both the complaints process and regulation generally.

Findings

– A total of 118 papers dealing with regulation of health complaints or disciplinary proceedings were located. The review reveals a shift away from self-regulation towards greater external oversight, including innovative regulatory approaches including “networked governance” and flexible or “responsive” regulation. It reports growing interest in adoption of strategic and responsive approaches to health complaints governance, by rejecting traditional legal forms in favor of more strategic and responsive forms, taking account of the complexity of adverse health events by tailoring responses to individual circumstances of complainants and their local environments.

Originality/value

– The challenge of how to collect and harness complaints data to improve the quality of healthcare at a systemic level warrants further research. Scope also exists for researching health complaints commissions and other “meta-regulatory” bodies to explore how to make these processes fairer and better able to meet the complex needs of complainants, health professionals, health services and society.

Patient complaints in healthcare systems: a systematic review and coding taxonomy

Background

Patient complaints have been identified as a valuable resource for monitoring and improving patient safety. This article critically reviews the literature on patient complaints, and synthesises the research findings to develop a coding taxonomy for analysing patient complaints.

Methods

The PubMed, Science Direct and Medline databases were systematically investigated to identify patient complaint research studies. Publications were included if they reported primary quantitative data on the content of patient-initiated complaints. Data were extracted and synthesised on (1) basic study characteristics; (2) methodological details; and (3) the issues patients complained about.

Results

59 studies, reporting 88 069 patient complaints, were included. Patient complaint coding methodologies varied considerably (eg, in attributing single or multiple causes to complaints). In total, 113 551 issues were found to underlie the patient complaints. These were analysed using 205 different analytical codes which when combined represented 29 subcategories of complaint issue. The most common issues complained about were ‘treatment’ (15.6%) and ‘communication’ (13.7%). To develop a patient complaint coding taxonomy, the subcategories were thematically grouped into seven categories, and then three conceptually distinct domains. The first domain related to complaints on the safety and quality of clinical care (representing 33.7% of complaint issues), the second to the management of healthcare organisations (35.1%) and the third to problems in healthcare staff–patient relationships (29.1%).

Conclusions

Rigorous analyses of patient complaints will help to identify problems in patient safety. To achieve this, it is necessary to standardise how patient complaints are analysed and interpreted. Through synthesising data from 59 patient complaint studies, we propose a coding taxonomy for supporting future research and practice in the analysis of patient complaint data.

What is the profile of patients thinking of litigation? Results from the hospitalized and outpatients' profile and expectations study

BACKGROUND

Patients vary considerably in their intentions to pursue legal action following a medical error. The aim of this study was to explore predictors of litigious intentions in both hospitalized patients and outpatients, determining the relative influences of patients' characteristics, help-seeking behavior, information-seeking attitudes and general health status factors.

METHODS

A representative cross-section of the urologic clinic of a general academic hospital and the associated outpatient clinic was used (a total of 226 patients, 145 outpatients). Data were gathered using in-person interviews conducted by trained psychologists. Attitudes were assessed by "General statements about medical errors", while expectations for information by "Krantz's Health Opinion Survey" (KHOS).

RESULTS

A single multivariate model explained 21.5% of the variance of litigious intentions. Younger age (explained 7.6% of the variation, p=0.04), weaker relationship with religion (4%, p=0.02), less than 15 visits/year to any physician (7.2%, p=0.001), outpatient status (2.4%, p=0.02), and higher expectations for information were associated with higher possibility to consider suing their physician (7.6%, p=0.002). Patients' desire for disclosure of a medical error (agreement in 82.2%) exceeded their expectations for financial compensation, particularly in less severe cases (agreement in 24.1%).

CONCLUSIONS

This is the first report on the profile of patients with high potential for malpractice suits as predicted by patients' age, relationship with religion, health-seeking and information-seeking behavior. Respecting patients' need for information during clinical consultations and proceeding to disclosure of medical errors, when they occur, seems to be not only the more patient-centered approach, but also the best way to lessen the likelihood of a claim. Hippokratia 2014; 18 (2):139-143.

Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety

Background

Practicing safe behavior regarding patients is an intrinsic part of a physician’s ethical and professional standards. Despite this, physicians practice behaviors that run counter to patient safety, including practicing defensive medicine, failing to report incidents, and hesitating to disclose incidents to patients. Physicians’ risk of malpractice litigation seems to be a relevant factor affecting these behaviors. The objective of this study was to identify conditions that influence the relationship between malpractice litigation risk and physicians’ behaviors.

Methods

We carried out an exploratory field study, consisting of 22 in-depth interviews with stakeholders in the malpractice litigation process: five physicians, two hospital board members, five patient safety staff members from hospitals, three representatives from governmental healthcare bodies, three healthcare law specialists, two managing directors from insurance companies, one representative from a patient organization, and one representative from a physician organization. We analyzed the comments of the participants to find conditions that influence the relationship by developing codes and themes using a grounded approach.

Results

We identified four factors that could affect the relationship between malpractice litigation risk and physicians’ behaviors that run counter to patient safety: complexity of care, discussing incidents with colleagues, personalized responsibility, and hospitals’ response to physicians following incidents.

Conclusion

In complex care settings procedures should be put in place for how incidents will be discussed, reported and disclosed. The lack of such procedures can lead to the shift and off-loading of responsibilities, and the failure to report and disclose incidents. Hospital managers and healthcare professionals should take these implications of complexity into account, to create a supportive and blame-free environment. Physicians need to know that they can rely on the hospital management after reporting an incident. To create realistic care expectations, patients and the general public also need to be better informed about the complexity and risks of providing health care.

Characteristics of complaints resulting in disciplinary actions against Danish GPs

OBJECTIVE

The risk of being disciplined in connection with a complaint case causes distress to most general practitioners. The present study examined the characteristics of complaint cases resulting in disciplinary action.

MATERIAL AND METHODS

The Danish Patients' Complaints Board's decisions concerning general practice in 2007 were examined. Information on the motives for complaining, as well as patient and general practitioner characteristics, was extracted and the association with case outcome (disciplinary or no disciplinary action) was analysed. Variables included complaint motives, patient gender and age, urgency of illness, cancer diagnosis, healthcare settings (daytime or out-of-hours services), and general practitioner gender and professional seniority.

RESULTS

Cases where the complaint motives involved a wish for placement of responsibility (OR = 2.35, p = 0.01) or a wish for a review of the general practitioner's competence (OR = 1.95, p = 0.02) were associated with increased odds of the general practitioner being disciplined. The odds of discipline decreased when the complaint was motivated by a feeling of being devalued (OR = 0.39, p = 0.02) or a request for an explanation (OR = 0.46, p = 0.01). With regard to patient and general practitioner characteristics, higher general practitioner professional seniority was associated with increased odds of discipline (OR = 1.97 per 20 additional years of professional seniority, p = 0.01). None of the other characteristics was statistically significantly associated with discipline in the multiple logistic regression model.

CONCLUSION

Complaint motives and professional seniority were associated with decision outcomes. Further research is needed on the impact of professional seniority on performance.

Patient complaint cases in primary health care: what are the characteristics of general practitioners involved?

Background. Limited knowledge exists about factors increasing the risk of general practitioners becoming involved in a complaint case or getting disciplined in connection with a complaint case. Aim. The present study aimed to identify the general practitioner and practice characteristics associated with complaint cases and discipline. Methods. Information on general practitioners involved in complaint case decisions during one year (2007) was linked to Danish National register data on all general practitioners (n = 3,765). Logistic regression was used for statistical analysis. Results. With regard to complaints concerning daytime services (n = 265), the professional seniority of the general practitioner was positively associated with the odds of receiving a complaint decision (OR = 1.44 per 20 years of seniority; CI 95%, 1.04–1.98). Likewise, having more consultations per day was associated with increased odds (OR = 1.29 per 10 extra consultations per day; CI 95%, 1.07–1.54). No statistically significant association could be demonstrated between being disciplined and general practitioner or practice characteristics. Conclusion. The possible relationship between professional seniority, rate of consultations, and complaint cases merits further studies to clarify the impact of professional seniority and workload on professional performance and to furthermore consider the role of factors such as job content and communication styles.

Comparing the outcome of two different procedures to handle complaints from a patient's perspective

AIM OF THE STUDY

To assess differences in patient satisfaction between a complaints procedure designed towards the needs of complainants (referred to here as the 'Committee') and a procedure that primarily aims at improving the professional quality of health care (referred to here as the 'Board').

METHOD

Patients' experiences and satisfaction were assessed through a questionnaire completed by 80 patients complaining to a Board and 335 to a complaints Committee. Only complainants with a complaint that was judged to be founded or partially founded were included.

RESULTS

Only half of the complainants reported being satisfied with the procedure they underwent. After controlling for differences in respondent characteristics, satisfaction with the Board was higher than with the Committee. The level of variance explained, however, was low (3%). The majority of respondents reported favourably on procedural aspects, for example, the impartiality of the procedure, and empathy demonstrated for their situation. Only a minority of complainants in both procedures believed that changes would be made as a result of their complaint.

DISCUSSION

The absence, in the eyes of most complainants, of tangible results of filing a complaint in both rather formal procedures may serve as an explanation for both the low level of overall satisfaction and the fact that the procedure which was developed specifically for patients did not perform better. To resolve the problem of low satisfaction with complaints handling, procedures should be developed that offer a basic degree of procedural safety. But this procedural safety should not stand in the way of what complainants really want: changes for the better.

The heart of health care: parents' perspectives on patient safety

Behind the wall of silence in health care are the unanswered questions of parents whose children experienced harm at the hands of their caregivers. In an industry where information and communication are crucial to quality, parents' voices often go unheard. Although that has begun slowly to change, providers could benefit from following the HEART model of service recovery, which includes hearing the concerns of patients and their families, empathizing with them, apologizing when care goes wrong, responding to parents' concerns with openness, and thanking the patient and family.

How do hospitals handle patients complaints? An overview from the Paris area

BACKGROUND

The incidence of complaints about health care has been rising. Reviewing the reasons why patients complain and how hospital staff respond to them can participate in an evaluation of quality in health care. There is a dearth of published information on complaints handling.

METHODS

In order to analyse complaints handling, we surveyed complaints referred to hospital managers in two French hospitals over one year: characteristics of complaints and characteristics of responses made to complainants. We used a scale for 10 criteria evaluating the responses to complaints.

RESULTS

A total of 115 complaints were analysed. Complaints mainly concerned the communication, the quality of medical care, waiting delays, and inadequate bills. Consequences of dissatisfaction included loss of confidence and refusal to pay the bill. Complainants wanted an explanation, their bill to be reduced, or something to change after the complaint. Most complainants wrote to the hospital manager. Hospital managers answered, using medical information as a basis for their responses. Median response time was 23 days. Interobserver agreement on evaluation criteria was almost perfect, substantial or moderate for 8 of 10 criteria. Major weaknesses of the responses were their lack of comprehensiveness (52%), the absence of intention to investigate (50%) and to act (77%), and of practical support (51%). The response of hospital managers misinterpreted the medical information given by the physician concerned in 5 (11%) of 45 cases.

CONCLUSION

We suggest that quality of complaints handling should be improved, possibly through the systematic reception of complainants by a physician not involved in the patient's care.

Factors predicting coroners' decisions to hold discretionary inquests

BACKGROUND

Coroners in Australia, Canada, New Zealand and other countries in the Commonwealth hold inquests into deaths in two situations. Mandatory inquests are held when statutory rules dictate they must be; discretionary inquests are held based on the decisions of individual coroners. Little is known as to how and why coroners select particular deaths for discretionary inquests.

METHODS

We analyzed the deaths investigated by Australian coroners for a period of seven and one-half years in five jurisdictions. We classified inquests as mandatory or discretionary. After excluding mandatory inquests, we used logistic regression analysis to identify the factors associated with coroners' decisions to hold discretionary inquests.

RESULTS

Of 20 379 reported deaths due to external causes, 1252 (6.1%) proceeded to inquest. Of these inquests, 490 (39.1%) were mandatory and 696 (55.6%) were discretionary. In unadjusted analyses, the rates of discretionary inquests varied widely in terms of age of the decedent and cause of death. In adjusted analyses, the odds of discretionary inquests declined with the age of the decedent; the odds were highest for children (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.54-3.06) and lowest for people aged 65 years and older (OR 0.38, 95% CI 0.28-0.51). Using poisoning as a reference cause of death, the odds of discretionary inquests were highest for fatal complications of medical care (OR 12.83, 95% CI 8.65-19.04) and lowest for suicides (OR 0.44, 95% CI 0.30-0.65).

INTERPRETATION

Deaths that coroners choose to take to inquest differ systematically from those they do not. Although this vetting process is invisible, it may influence the public's understanding of safety risks, fatal injury and death.

Can Money Symbolize Acknowledgment? How Victims' Relatives Perceive Monetary Awards for Their Emotional Harm

Legal systems differ markedly on how they treat the emotional harm suffered by close family members of crime or accident victims. This paper reports the results of two empirical studies examining how citizens whose child, partner, or parent was killed or seriously injured as a result of violent crime or tort (secondary victims) perceive a monetary award for their own non-economic harm relating to the death or injury of their loved one. The objective of our research was to test the Dutch legislator's assumption that a (modest) monetary award for secondary victims' emotional harm can have a meaningful symbolic value by providing recognition and satisfaction. Until then, no compensation was available for such harm under Dutch law. In addition, we examined whether victims' relatives preferred standardization or individuation in determining the amount of the award, how they evaluated the amount, and the manner in which such awards might be offered. In a first quantitative survey study conducted in the Netherlands, 726 secondary victims were asked for their evaluations of such awards for the emotional harm they suffered as a result of the death or injury of their family member. We also asked our representative sample about their actual experience of the legal process in order to put their evaluations of such awards into context. In a second qualitative study, conducted in Belgium, interviews were held with 14 secondary victims who had actually received an award for their own emotional harm under Belgian law (study 2). Results suggest that secondary victims regard an award for emotional harm as a positive gesture and may interpret it as helping to satisfy relatives' psychological concerns by seeing it, for example, as an acknowledgment of loss and responsibility. Overall findings suggest that victims' relatives may be seeking acknowledgement of their emotional losses and the norm violation.

Physicians' explanatory behaviours and legal liability in decided medical malpractice litigation cases in Japan

BACKGROUND

A physician's duty to provide an adequate explanation to the patient is derived from the doctrine of informed consent and the physician's duty of disclosure. However, findings are extremely limited with respect to physicians' specific explanatory behaviours and what might be regarded as a breach of the physicians' duty to explain in an actual medical setting. This study sought to identify physicians' explanatory behaviours that may be related to the physicians' legal liability.

METHODS

We analysed legal decisions of medical malpractice cases between 1990 and 2009 in which the pivotal issue was the physician's duty to explain (366 cases). To identify factors related to the breach of the physician's duty to explain, an analysis was undertaken based on acknowledged breaches with regard to the physician's duty to explain to the patient according to court decisions. Additionally, to identify predictors of physicians' behaviours in breach of the duty to explain, logistic regression analysis was performed.

RESULTS

When the physician's explanation was given before treatment or surgery (p = 0.006), when it was relevant or specific (p = 0.000), and when the patient's consent was obtained (p = 0.002), the explanation was less likely to be deemed inadequate or a breach of the physician's duty to explain. Patient factors related to physicians' legally problematic explanations were patient age and gender. One physician factor was related to legally problematic physician explanations, namely the number of physicians involved in the patient's treatment.

CONCLUSION

These findings may be useful in improving physician-patient communication in the medical setting.

Disclosure of patient safety incidents: a comprehensive review

PURPOSE

Adverse events are increasingly recognized as a source of harm to patients. When such harm occurs, problems arise in communicating the situation to patients and their families. We reviewed the literature on disclosure across individual and international boundaries, including patients', healthcare professionals' and other stakeholders' perspectives in order to ascertain how the needs of all groups could be better reconciled.

DATA SOURCES

A systematic review of the literature was carried out using the search terms 'patient safety', 'medical error', 'communication', 'clinicians', 'healthcare professionals' and 'disclosure'. All articles relating to either patients' or healthcare professionals' experiences or attitudes toward disclosure were included.

RESULTS

Both patients and healthcare professionals support the disclosure of adverse events to patients and their families. Patients have specific requirements including frank and timely disclosure, an apology where appropriate and assurances about their future care. However, research suggests that there is a gap between ideal disclosure practice and reality. Although healthcare is delivered by multidisciplinary teams, much of the research that has been conducted has focused on physicians' experiences. Research indicates that other healthcare professionals also have a role to play in the disclosure process and this should be reflected in disclosure policies.

CONCLUSIONS

This comprehensive review, which takes account of the perspectives of the patient and members of the care team across multiple jurisdictions, suggests that disclosure practice can be improved by strengthening policy and supporting healthcare professionals in disclosing adverse events. Increased openness and honesty following adverse events can improve provider-patient relationships.

Legal rehabilitation of health professionals in New Zealand

Aims

A common understanding of ‘rehabilitation’ is the restoration of physical or mental functioning. However, sometimes the concept is applied by professional disciplinary bodies to restore poorly performing health practitioners to their former level of professional functioning. This article aims to research what ‘rehabilitation’ means, in the context of New Zealand law.

Methods

A range of cases were considered to assess what rehabilitation consists of, and when disciplinary boards choose to use it. Where discrepancies between decisions gave rise to questions, further analysis was carried out.

Findings

It can be seen that the New Zealand's disciplinary decisions do not appear consistent, particularly differing by profession. Nevertheless, a clearer approach is beginning to emerge, one which should become more so in the future.

Conclusions

Analysis of New Zealand's disciplinary decisions may contribute to the rich international research on professional regulation.

Healthcare safety committee in Japan: mandatory accountability reporting system and punishment

PURPOSE OF REVIEW

The publication of To Err is Human by the Institute of Medicine highlighted the increased international concern about patient safety. Each country has developed its own medical adverse event reporting system. In 2007, the Japanese government attempted to establish a new accountability system in medicine, after an obstetrician was arrested for manslaughter. This paper reviews how this accountability system affected Japanese physicians' behavior, and describes different types of medical adverse event reporting systems.

RECENT FINDINGS

In general, reporting of adverse event systems can be either mandatory or voluntary, with the purpose being either for learning or for accountability. The goal of a newly proposed mandatory accountability system from the Japanese government was to investigate the cause of death in medical cases in order to clarify liability. Reports generated by this system could potentially be cited in civil law suits, administrative sanctions, and criminal prosecutions. After announcement of this new system, Japanese physicians began to act defensively, fearing criminal prosecution. Refusing to see high-risk patients and 'bouncing' (sometimes referred to as 'turfing' or 'dumping') to other hospitals became national phenomena. In addition, medical school graduates began avoiding highly legally vulnerable specialties. Even though this new system is not yet legalized in Japan, at least 153 obstetrics hospitals and 3320 clinics have closed.

SUMMARY

The new system of investigating medical adverse events in Japan allows for incident reports to be utilized in court. This has led to widespread fear of prosecution and defensive medicine. The lessons from Japan should be considered when other countries implement nationwide accountability systems.

Disclosing medical errors to patients: it's not what you say, it's what they hear

BACKGROUND

There is consensus that patients should be told if they are injured by medical care. However, there is little information on how they react to different methods of disclosure.

OBJECTIVE

To determine if volunteers' reactions to videos of physicians disclosing adverse events are related to the physician apologizing and accepting responsibility.

DESIGN

Survey of viewers randomized to watch videos of disclosures of three adverse events (missed mammogram, chemotherapy overdose, delay in surgical therapy) with designed variations in extent of apology (full, non-specific, none) and acceptance of responsibility (full, none).

PARTICIPANTS

Adult volunteer sample from the general community in Baltimore.

MEASUREMENTS

Viewer evaluations of physicians in the videos using standardized scales.

RESULTS

Of 200 volunteers, 50% were <40 years, 25% were female, 80% were African American, and 50% had completed high school. For designed variations, scores were non-significantly higher for full apology/responsibility, and lower for no apology/no responsibility. Perceived apology or responsibility was related to significantly higher ratings (chi-square, 81% vs. 38% trusted; 56% vs. 27% would refer, p < 0.05), but inclination to sue was unchanged (43% vs. 47%). In logistic regression analyses adjusting for age, gender, race and education, perceived apology and perceived responsibility were independently related to higher ratings for all measures. Inclination to sue was reduced non-significantly.

CONCLUSIONS

Patients will probably respond more favorably to physicians who apologize and accept responsibility for medical errors than those who do not apologize or give ambiguous responses. Patient perceptions of what is said may be more important than what is actually said. Desire to sue may not be affected despite a full apology and acceptance of responsibility.