Acute aortic syndrome and radiology liability in Italy: Case reports and medico-legal considerations

The trend for medical malpractice claims has increased in recent years, both in the USA and in Europe. Although diagnostic radiology is not considered a high-risk field, malpractice claims in this area follow this general trend. The most common legal action taken against radiologists includes failure to diagnose, poor communication between physicians, failure to supervise technologists properly and improper procedures. Recently, the Italian Civil Supreme Court delivered a judgment (Cass. Civ., N.10158-18) regarding the liability of radiologists, stating that in radiological practice, a correct and timely execution of the diagnostic investigation is required. By contrast, the same judgment states that requesting further clinical consultations and/or the execution of in-depth diagnostic examinations are not within their duties. Considering this judgment, we report two cases of radiologist malpractice and related responsibility for negligent conduct regarding the diagnosis of thoracic aortic dissection and the prevention and management of acute aortic syndrome.

[Medical disciplinary boards punish more often and more severely; an observational study of 10 years of medical disciplinary law]

OBJECTIVE

To examine if the medical disciplinary law in the Netherlands is becoming tougher.

DESIGN

Observational study.

METHOD

We read the annual reports of the Dutch Disciplinary Committees for the Healthcare Sector 2007-2017, and registered the numbers of disciplinary cases and those cases upheld, the measures imposed and the degree of consistency in the event of an appeal. Over 400 medical disciplinary cases were reviewed in more detail. Based on these cases, we determined those variables that increase or decrease the likelihood of conviction, such as the gender of the defendants, the region in which the disciplinary case was heard, and if objective norms and professional practice guidelines had been used in arriving at the verdict.

RESULTS

Each year a disciplinary case is brought against an average of 0.4% of all health care providers - mainly physicians (an average of approximately 1400 disciplinary cases each year). One-third of all disciplinary cases were dealt with in court and about half of them were upheld. Over time, the number of disciplinary cases has increased (36%), as has the percentage of cases that are upheld (27%). Additionally, heavier measures were more often imposed and the degree of consistency between the initial ruling and the ruling on appeal also increased (56%). Those factors that increased the likelihood of a case being upheld were: being a physician of male gender, the disciplinary case being heard in The Hague or Eindhoven, and the non-implementation of an objective norm or professional practice guideline in arriving at the verdict.

CONCLUSION

Since 2007 the Dutch medical disciplinary boards have been punishing more often and more severely. This may be because the subjective demands made on health care professionals have changed. Arriving at an opinion subjectively is not a problem when it comes to verifying compliance with standards of due care. However, if this method is used to determine the penalty, the health care system will become defensive - and this will not improve the quality of care.

[Investigation into medical disciplinary law critically examined]

There is a suggestion that the medical disciplinary committees (MDC) in the Netherlands are making more severe rulings on medical professionals. In a 10-year analysis of MDC rulings, it appears that complaints made by patients are more frequently being judged to be well-founded, and that the measures being taken are more severe. The authors conclude that there is a numerical basis for the increasing severity of the rulings. However, a numerical trend as such does not constitute proof of this, as the way in which the ruling is arrived at is unknown. A more thorough analysis of the patient complaints, the ruling and the underlying arguments is necessary. The authors also make some other statements that can be refuted. The importance of the possible influence of the increasing complexity of health care as a factor in the increase in complaints to the MDC is not addressed.

Characteristics of Paid Malpractice Claims Among Resident Physicians From 2001 to 2015 in the United States

PURPOSE

Limited information exists about medical malpractice claims against physicians-in-training. Data on residents' involvement in malpractice actions may inform perceptions about medicolegal liability and influence clinical decision-making at a formative stage. This study aimed to characterize rates and payment amounts of paid malpractice claims on behalf of resident physicians in the United States.

METHOD

Using data from the National Practitioner Data Bank, 1,248 paid malpractice claims against resident physicians (interns, residents, and fellows) from 2001 to 2015, representing 1,632,471 residents-years, were analyzed. Temporal trends in overall and specialty-specific paid claim rates, payment amounts, catastrophic (> $1 million) and small (< $100,000) payments, and other claim characteristics were assessed. Payment amounts were compared with attending physicians during the same time period.

RESULTS

The overall paid malpractice claim rate was 0.76 per 1,000 resident-years from 2001 to 2015. Among 1,194 unique residents with paid claims, 95.7% had exactly 1 claim, while 4.3% had 2-4 claims during training. Specialty-specific paid claim rates ranged from 0.12 per 1,000 resident-years (pathology) to 2.96 (obstetrics and gynecology). Overall paid claim rates decreased by 52% from 2001-2005 to 2011-2015 (95% confidence interval [CI]: 0.45, 0.59). Median inflation-adjusted payment amount was $199,024 (2015 dollars), not significantly different from payments made on behalf of attending physicians during the same period. Proportions of catastrophic (11.2%) and small (33.1%) claims did not significantly change over the study period.

CONCLUSIONS

From 2001 to 2015, paid malpractice claim rates on behalf of resident physicians decreased by 52%, while median payment amounts were stable. Resident paid claim rates were lower than attending physicians, while payment amounts were similar.

Trends and Risk Factors in Orthopedic Lawsuits: Analysis of a National Legal Database

Orthopedic surgeons frequently encounter medical malpractice claims. The purpose of this study was to assess trends and risk factors in lawsuits brought against orthopedic surgeons using a national legal database. A legal research service was used to search publicly available settlement and verdict reports between 1988 and 2013 by terms "orthopaedic or orthopedic" and "malpractice." Temporal trends were evaluated, and logistic regression was used to identify independent risk factors for case outcomes. A total of 1562 publicly reported malpractice cases brought against orthopedic surgeons, proceeding to trial during a 26-year period, were analyzed. The plaintiffs won 462 (30%) cases, with a mean award of $1.4 million. The frequency of litigation and pay-outs for plaintiffs increased 215% and 280%, respectively, between the first and last 5-year periods. The mean payout for plaintiff-favorable verdicts was highest in pediatrics ($2.6 million), followed by spine ($1.7 million) and oncology ($1.6 million). Fracture fixation (363 cases), arthroplasty (290 cases), and spine (231 cases) were the most commonly litigated procedures, while plaintiffs were most successful for fasciotomy (48%), infection-treating procedures (43%), and carpal tunnel release (37%). When analyzing data by state and region, adjusted for population, northeastern states had a higher frequency of lawsuits. Malpractice liability has increased during the past 3 decades while orthopedic surgeons continue to win most of the cases making it to court. As patients search for medical care via publicly available information, it is important for orthopedic surgeons to understand what aspects of their own practice carry different risks of litigation. [Orthopedics. 2019; 42(2):e260-e267.].

Medical errors, malpractice, and defensive medicine: an ill-fated triad

For the first 180 years following the founding of the US, physicians occasionally were sued for medical malpractice. Allegations of negligence were errors of commission - i.e. the physician made a mistake by doing something wrong, usually mistreatment of a fracture or dislocation, a complication or death following a surgical procedure, prescribing the wrong medication, and after the discovery of the X-ray by Roentgen in 1895, causing radiation burns. In the mid twentieth century malpractice allegations slowly changed from errors of commission to errors of omission - i.e. the physician failed to do something right: almost always, failed to make a diagnosis. The number of malpractice lawsuits increased at a geometric rate beginning in the 1960s, and in the 1970s physicians began practicing defensive medicine, which lead physicians to order unnecessary radiology exams and tests. In the past 20 years the number of malpractice lawsuits has been decreasing, but the practice of defensive medicine has continued. Unnecessary exams and tests increase the likelihood of overdiagnosis and overtreatment, i.e. a new kind of error of commission.

[More and higher claims for damages: analysis of claims for damages in Dutch hospital care 2007-2016]

OBJECTIVE

To investigate the number and extent of claims concerning hospital care at a national level, thereby affording insight to the profession.

DESIGN

A quantitative, descriptive and comparative study.

METHOD

We used anonymised data on all claims for damages from regular hospital care that were submitted to Centramed and MediRisk between 1 January 2007 and 31 December 2016. Between them, these two companies are the insurers of 95% of all Dutch hospitals. Using SPSS and Mathematica, we analysed the number of claims submitted, the average duration of the procedures, the manner in which they were settled, developments in the total cost of claims, and the settlements paid out to claimants.

RESULTS

A total of 15,115 claims were made between 2007 and 2016. Up to 2013, the number of claims increased annually, thereafter this stabilised. In 2016, 4.5% more claims were submitted than in 2007. During the same period, 15,306 claims were closed. The total claim-related cost was € 229,191,033 and showed a clearly rising trend throughout this period. In 2016 the cost of claims was four-and-a-half times as high as in 2007.

CONCLUSION

The number of claims being made is rising, but not as quickly as the cost of claims which increased fivefold during the period under investigation. Compared with previous investigations, both the number and the extent of the claims increased significantly between 2007 and 2016.

Trends in malpractice claims for obstetric and gynecologic procedures, 2005 through 2014

BACKGROUND

Interest in medical malpractice and areas of medicolegal vulnerability for practicing obstetricians and gynecologists has grown substantially, and many providers report changing surgical practice out of fear of litigation. Furthermore, education on medical malpractice and risk management is lacking for obstetrics and gynecology trainees. Recent obstetric and gynecologic malpractice claims data are lacking. We report on recent trends in malpractice claims for obstetrics and gynecology procedures, and compare these trends to those of other medical specialties.

OBJECTIVE

We sought to evaluate recent trends in malpractice claims for obstetrics and gynecology procedures and compare these to other medical specialties.

STUDY DESIGN

A search was performed on all medicolegal claims data for obstetrics and gynecology procedures from Jan. 1, 2005, through Dec. 31, 2014, using the Physician Insurers' Association of America data-sharing project, which was created to identify medical professional liability trends. Data from 20 insurance carriers were reviewed based on a search using International Classification of Diseases, Ninth Revision codes and unique database-specific codes.

RESULTS

Of the 10,915 total claims closed from 2005 through 2014, the majority (59.5%) were dropped, withdrawn, or dismissed. The average indemnity of the remaining paid claims (31.1%) was $423,250. The most frequently litigated procedure was operative procedures on the uterus; 27.8% of cases were paid with an average indemnity of $279,384. The procedure associated with the highest proportion of paid claims was vacuum extraction. The average indemnity for paid obstetrics and gynecology procedural claims was 27% higher than that for all medical specialties combined. Obstetrics and gynecology procedural claims had the second highest average indemnity payment and the fifth highest paid-to-closed ratio of all medical specialties.

CONCLUSION

Litigation claims for obstetrics and gynecology procedures have higher average indemnity payments and higher paid-to-closed ratios than most other medical specialties. Claims most frequently relate to gynecologic surgery, but obstetric procedures are more expensive. Possible factors may include procedural experience and unique perioperative complications. We encourage efforts addressing procedures, litigation, and quality interventions to improve outcomes, mitigate risk, and potentially lower indemnity payments.

[Medical negligence]

Medical negligence is a matter of growing public interest. This review outlines various aspects of medical negligence: epidemiology, taxonomy, and the risks, causes, psychology, management and prevention of errors.

Informed consent and Italian physicians: change course or abandon ship--from formal authorization to a culture of sharing

In Italy in recent years, an exponential increase in the frequency of medical malpractice claims relating to the issue of informed consent has substantially altered not only medical ethics, but medical practice as well. Total or partial lack of consent has become the cornerstone of many malpractice lawsuits, and continues to be one of the primary cudgels against defendant physicians in Italian courtrooms. Physicians have responded to the rising number of claims with an increase in 'defensive medicine' and a prevailing preoccupation with the purely formal aspects of consent. The result is a plethora of consent forms, believed to be a guarantee of 'informed consent', as well as a growing reliance on informed consent as a shield against judicial action brought by the patient. Physicians 'inform' patients without really sharing information, often delegating the task of communication to other professionals who are not doctors. Italian judges always condemn the physician when information to the patient has been inadequate, thus leading insurance companies to consider the lack of valid informed consent as the total responsibility of the physician and/or the hospital. It is necessary to change tack, to remove this idea of consent which permeates the defensive culture of medical practice. Italian physicians need to be trained, first of all, to become aware that information and consent are two distinct processes, albeit closely connected. Valid communication (in which there is information and consent) demands a higher level of professionalism from physicians.

What ails the practice of medicine: the Atlas has shrugged

Health-care providers are currently facing a huge challenge. At one end they are expending a huge amount of time and energies on health-care delivery including time spent on upgradation of their knowledge and skills (to remain abreast with the field and be able to provide state-of-art patient care), sometimes even at the expense of themselves and their families. On the other hand they are not receiving adequate re-imbursement for their efforts. To compound the problem several "traders" have entered the profession who are well adept in the materialistic approach abandoning the ethics (which currently happens to be the flavor of society in general), giving a bad name to the whole profession and causing severe grief, embarrassment and even dis-illusion to an average physician. The solution to the problem may lie in weeding out these "black sheep" as also realization by the society that the whole profession should not be wrongly labeled, rather a hard toiling and a morally driven practitioner should be given his/her due worth.

[The WKKGZ, a new act with far-reaching consequences for physicians]

The introduction of the Act on Quality, Complaints and Disputes in Health care (WKKGZ) on 1 January 2016, brings changes for physicians in the Netherlands. Even though not all the implications of the Act are yet known, it is clear that the new provisions on quality entail a substantial increase in the administrative workload. With respect to the right of complaint a great deal will change for physicians and other care providers. Independent complaints committees are no longer mandatory. They are to be replaced by dispute settlement authorities that are able to make binding decisions with the possibility of awarding damages for patient claims. The legal position of physicians is not satisfactorily regulated in a well-balanced way in all areas, and deserves further attention.

NO-FAULT COMPENSATION FOR MEDICAL INJURIES: TRENDS AND CHALLENGES

As an alternative to the tort or fault-based system, a no-fault compensation system has been viewed as having the potential to overcome problems inherent in the tort system by providing fair, speedy and adequate compensation for medically injured victims. Proponents of the suggested no-fault compensation system have argued that this system is more efficient in terms of time and money, as well as in making the circumstances in which compensation is paid, much clearer. However, the arguments against no-fault compensation systems are mainly on issues of funding difficulties, accountability and deterrence, particularly, once fault is taken out of the equation. Nonetheless, the no-fault compensation system has been successfully implemented in various countries but, at the same time, rejected in some others, as not being implementable. In the present trend, the no-fault system seems to fit the needs of society by offering greater access to justice for medically injured victims and providing a clearer "road map" towards obtaining suitable redress. This paper aims at providing the readers with an overview of the characteristics of the no fault compensation system and some examples of countries that have implemented it.

METHODOLOGY

Qualitative Research-Content Analysis.

RESULTS

Given the many problems and hurdles posed by the tort or fault-based system, it is questionable that it can efficiently play its role as a mechanism that affords fair and adequate compensation for victims of medical injuries. However, while a comprehensive no-fault compensation system offers a tempting alternative to the tort or fault-based system, to import such a change into our local scenario requires a great deal of consideration. There are major differences, mainly in terms of social standing, size of population, political ideology and financial commitment, between Malaysia and countries that have successfully implemented no-fault systems. Nevertheless, implementing a no-fault compensation system in Malaysia is not entirely impossible. A custom-made no-fault model tailored to suit our local scenario can be promising, provided that a thorough research is made, assessing the viability of a no-fault system in Malaysia, addressing the inherent problems and, consequently, designing a workable no-fault system in Malaysia.

Liability impact of the hospitalist model of care

BACKGROUND

An increasingly large proportion of inpatient care is provided by hospitalists. The care discontinuities inherent to hospital medicine raise concerns about malpractice risk. However, little published data exist on the medical liability risks associated with care by hospitalists.

OBJECTIVE

We sought to determine the risks and outcomes of malpractice claims against hospitalists in internal medicine.

DESIGN

Retrospective observational analysis.

MEASUREMENTS

Using claims data from a liability insurer-maintained database of over 52,000 malpractice claims, we measured the rates of malpractice claims against hospitalists compared to other physician specialties, types of allegations against hospitalists, contributing factors, and the severity of injury in and outcomes of these claims.

RESULTS

Hospitalists had a malpractice claims rate of 0.52 claims per 100 physician coverage years (PCYs), which was significantly lower than that of nonhospitalist internal medicine physicians (1.91 claims per 100 PCYs), emergency medicine physicians (3.50 claims per 100 PCYs), general surgeons (4.70 claims per 100 PCYs), and obstetricians-gynecologists (5.56 claims per 100 PCYs) (P < 0.001 for all comparisons). The most common allegation types made against hospitalists were for errors in medical treatment (41.5%) and diagnosis (36.0%). The most common contributing factors underlying claims were deficiencies in clinical judgment (54.4%) and communication (36.4%). Of the claims made against hospitalists, 50.4% involved the death of the patient.

CONCLUSIONS

Despite fears of increased liability from the hospitalist model of care, hospitalists in internal medicine are subject to medical malpractice claims less frequently when compared to other internal medicine physicians and specialties.

The medical liability climate and prospects for reform

For many physicians, the prospect of being sued for medical malpractice is a singularly disturbing aspect of modern clinical practice. State legislatures have enacted tort reforms, such as caps on damages, in an effort to reduce the volume and costs of malpractice litigation. Attempts to introduce similar traditional reform measures at the federal level have so far failed. Much less prominent, but potentially more important, are proposed alternative approaches for resolving medical injuries; a number of these efforts are currently being tested in federally sponsored demonstration projects. These nontraditional reforms have considerable promise for addressing some of the system's most challenging issues, including high costs and barriers to accessing compensation. In this Special Communication, we review recent national trends in medical liability claims and costs, which indicate a sharp reduction in the rate of paid claims and flat or declining levels in compensation payments and liability insurance costs over the last 7 to 10 years. We discuss a number of nontraditional reform approaches--communication-and-resolution programs, presuit notification and apology laws, safe harbor legislation, judge-directed negotiation, and administrative compensation systems--and we conclude by describing several forces likely to shape change in the medical liability environment over the next decade.

[Dentistry and healthcare legislation 11. The dentist and the civil law judge: claims]

In contrast to the law governing complaints and to disciplinary law, a civil law judge can sentence dentists to the restoration of all damages to patients. For this to happen, there has to be evidence of damage, responsibility and a causal connection. For the assumption of responsibility as well as a causal connection, an important question is whether a dentist has violated a relevant guideline or protocol. Moreover, dentists are not only responsible for their own mistakes, but also, in principle, for those of their employees. Depending on the situation, dentists can also be held accountable for the mistakes of a dentist who is working in their practice on a self-employed basis. Dutch dentists do not yet have to fear American situations', because damages awarded in The Netherlands are still relatively low.

Legal briefing: informed consent in the clinical context

This issue's "Legal Briefing" column covers recent legal developments involving informed consent.1 We covered this topic in previous articles in The Journal of Clinical Ethics.2 But an updated discussion is warranted. First, informed consent remains a central and critically important issue in clinical ethics. Second, there have been numerous significant legal changes over the past year. We categorize recent legal developments into the following 13 categories: (1) Medical Malpractice Liability, (2) Medical Malpractice Liability in Wisconsin, (3) Medical Malpractice Liability in Novel Situations, (4) Enforcement by Criminal Prosecutors, (5) Enforcement by State Medical Boards, (6) Enforcement through Anti-Discrimination Laws, (7) Statutorily Mandated Disclosures Related to End-of-Life Counseling, (8) Statutorily Mandated Disclosures Related to Aid in Dying, (9) Statutorily Mandated Disclosures Related to Abortion, (10) Statutorily Mandated Disclosures Related to Telemedicine, (11) Statutorily Mandated Disclosures Related to Other Interventions, (12) Statutorily Mandated Gag and Censorship Laws, (13) Informed Consent in the Research Context.

New Zealand's 2005 'no-fault' compensation reforms and medical professional accountability for harm

AIMS

To discover the effect of the 2005 'no-fault' compensation reforms on medical professional accountability for harm in the context of overall trends in New Zealand's medical professional accountability processes 2001-2010.

METHODS

Data for the 5 years before and after the 2005 reforms were compared including compensation claims to the Accident Compensation Corporation (ACC), ACC reporting to the authorities, patient complaints to the Health and Disability Commissioner and outcomes, referrals to the Medical Council and outcomes, and disciplinary proceedings and outcomes.

RESULTS

Following the 2005 compensation reforms, claims for compensation increased, ACC reporting overall increased but ACC reporting to the Medical Council decreased; patient complaints increased but the Health and Disability Commissioner investigated fewer complaints and referred fewer doctors for discipline while maintaining steady referrals to the Medical Council; referrals to the Medical Council decreased, and the Medical Council conducted fewer performance reviews and referred fewer doctors for discipline; disciplinary proceedings decreased but more hearings ended in guilty findings.

CONCLUSIONS

Accountability via compensation decreased following the 2005 'no-fault' compensation reforms, contributing to an overall decrease in medical professional accountability for harm.

Peculiarities of medication safety

The modern concept of patient safe medical treatment lays responsibility for undesirable complications on lacks of healthcare system (structural, organizational and operative); not on medical workers or products of medical purpose. A spirit to comprehension of scales of a problem of a safety the sharp increase of number of judicial claims in occasion of causing harm has served health of patients. If to the beginning of 1970 th in the USA one claim on 100 doctors to 2011 frequency of supply of claims has increased in 12 times was annually registered on the average, and average payment under claims has increased for the same period about 2000 dollars up to 1500000 dollars. The problem of ensuring patient safety is topical. 72 (24%) of the 300 patients interrogated by the authors have declared that at various times were victims of inadequate rendering of medical aid. Among them of 96 (32%) have specified an establishment to them of the wrong diagnosis or purpose of wrong treatment. Results from the current study show the necessity of creation in Georgia systems of monitoring to increase the security of treatment, participation in this business of patients, creation of special preventive and training programs for the medical personnel and students, strengthening of cooperation with the international organizations in area of improvement of quality and a security of medical aid.

Medical malpractice claims related to cataract surgery complicated by retained lens fragments (an American Ophthalmological Society thesis)

PURPOSE

To review malpractice claims associated with retained lens fragments during cataract surgery to identify ways to improve patient outcomes.

METHODS

Retrospective, noncomparative, consecutive case series. Closed claims data related to cataract surgeries complicated by retained lens fragments (1989 through 2009) from an ophthalmic insurance carrier were reviewed. Factors associated with these claims and claims outcomes were analyzed.

RESULTS

During the 21-year period, 117 (12.5%) of 937 closed claims associated with cataract surgery were related to retained lens fragments with 108 unique cataract surgeries, 97% against cataract surgeon and 3% against retinal surgeon. Twelve (11%) of 108 claims were resolved by a trial, 30 (28%) were settled, and 66 (61%) were dismissed. The defendant prevailed in 83% of trials. Indemnity payments totaling more than $3,586,000 were made in 32 (30%) of the claims (median payment, $90,000). The difference between the preoperative visual acuity and the final visual acuity was predictive of an indemnity payment (odds ratio [OR], 2.28; P=.001) and going to a trial (OR, 2.93; P=.000). Development of corneal edema was associated with an indemnity payment (OR, 3.50; P=.037). Timing of referral and elevated intraocular pressure (IOP) were statistically significant in univariate analyses but not in multivariate analyses for a trial.

CONCLUSIONS

Whereas the majority of claims were dismissed, claims associated with greater visual acuity decline, corneal edema, or elevated IOP were more likely to result in a trial or payment. Ways to reduce significant vision loss, including improved management of corneal edema and IOP, and timely referral to a subspecialist should be considered.

Perspectives on medical malpractice self-insurance financial reporting

Financial reporting of medical malpractice self-insurance is evolving. The Financial Accounting Standards Board Accounting Standards Codification Section 954-450-25 provides guidance for accounting and financial reporting for medical malpractice. Discounting of medical malpractice liabilities has been reassessed in recent years. Malpractice litigation reform efforts continue in several states. Accountable care organizations could increase the frequency of medical malpractice claims because of patients' heightened expectations regarding quality of care.

[Medical malpractice in ophthalmology]

BACKGROUND

The increasing number of patients taking action for medical malpractice (MM) is a burden for the medical practitioners accused. After the assessment through an arbitration committee, which is free of cost for the patients,a large number of lawsuits can be avoided. Discussion of patient complaints and analyzing cases of MM is an important concern for the medical community in order to reduce errors in treatment and to contribute to patient safety.

MATERIAL AND METHODS

The patient applications to the arbitration committee of the medical association of North-Rhine ("Gutachterkommission Nordrhein") for review of MM in the field of ophthalmology in the years 1999-2010 were analyzed statistically.

RESULTS

In the years 1999-2010 a total of 583 cases were related to ophthalmology (3% of all cases) and in 122 cases (21%) MM was recognized by the committee. In 61% of the cases MM was caused by errors in diagnosis, in 24% by errors in processes and in 15% by errors in surgical procedures.

CONCLUSIONS

The proportion of ophthalmological cases in the total number of MM cases is low. Most errors in diagnosis are caused by the lack of basic diagnostic on examination procedures. Errors in processes are caused by instrumental errors and deficient communication. An important reason for errors in surgical procedures is a deficient management of complications. A standardized workflow of medical examinations and a quality management can help to avoid MM.

Environmental market factors associated with physician career satisfaction

Previous research has found that physician career satisfaction is declining, but no study has examined the relationship between market factors and physician career satisfaction. Using a theoretical framework, we examined how various aspects of the market environment (e.g., munificence, dynamism, complexity) are related to overall career satisfaction. Nationally representative data from the 2008 Health Tracking Physician Survey were combined with environmental market variables from the 2008 Area Resource File. After controlling for physician and practice characteristics, at least one variable each representing munificence, dynamism, and complexity was associated with satisfaction. An increase in the market number of primary care physicians per capita was positively associated with physician career satisfaction (OR = 2.11, 95% CI: 1.13 to 3.9) whereas an increase in the number of specialists per capita was negatively associated with physician satisfaction (OR = 0.68, 95% CI: 0.48 to 0.97). Moreover, an increase in poverty rates was negatively associated with physician career satisfaction (OR = 0.95, 95% CI: 0.91 to 1.01). Lastly, physicians practicing in states with a malpractice crisis (OR = 0.81, 95% CI: 0.68 to 0.96) and/or those who perceived high competition in their markets (OR = 0.76, 95% CI: 0.61 to 0.95) had lower odds of being satisfied. A better understanding of an organization's environment could assist healthcare managers in shaping their policies and strategies to increase physician satisfaction.

A medical staff peer review system in a public teaching hospital--an internal quality improvement tool

Peer review of the quality of care of the medical staff in a healthcare delivery system, properly executed and utilized, can bring about changes that improve the quality and safety of patient care, enhance clinical performance, and augment physician education. Although all healthcare facilities are mandated to conduct peer reviews, the process of how it is conducted, reported, and utilized varies widely. In 2007, our institution, a large public teaching acute care facility, developed and implemented an electronic Medical Staff Peer Review System (MS-PRS) that replaced the existing paper-based system and created a centralized database for all peer review activities. Despite limited resources and mounting known challenges, we have developed and implemented a system that includes 100% mortality reviews, an ongoing random review for reappointment and operative procedures, and morbidity peer reviews. Parallel to the 4-year implementation of the system, we observed a steady, significant downward trend in the medical malpractice claim rate, which can be attributable in part to the implementation of MS-PRS. In this paper, we share our experiences in the development, outcomes, challenges encountered, and lessons learned from MS-PRS and provide our recommendations to similar institutions for the development of such a system.

Mammography and litigation

Mammography is perhaps the most heavily legislated medical procedure, and medical malpractice lawsuits are filed against mammographers for several reasons, including mammogram misread and delayed diagnosis. Perhaps the driving force behind mammography litigation is public perception of mammography's effectiveness. Surveys have indicated that the public attributes 100% sensitivity to mammography, whereas its actual sensitivity is approximately 79%. Fear of litigation affects mammography practice, and several initiatives have been suggested to address the problem of rampant mammography litigation, including increasing public awareness, to improve working conditions for mammographers and to ensure the future of this lifesaving procedure.

Increased number of ear-nose-throat malpractice complaints in Denmark

INTRODUCTION

Danish ear, nose and throat (ENT) physicians have little knowledge of the type of decisions made at the Danish National Board of Patients' Complaints (NBPC). The aim of this study was to analyze and describe the epidemiology of ENT malpractice complaints by showing their distribution and volume in order to facilitate learning and evaluate the underlying factors.

MATERIAL AND METHODS

This retrospective register study analyzed all ENT malpractice complaints processed by the NBPC in the 1998-2008 period.

RESULTS

In 18% of the 480 ENT malpractice complaints, the settlement resulted in criticism of one or more ENT health-care professionals. A steady increase in the number of ENT malpractice complaints was found over the study period and the total increase observed for the study period was 72%. Younger generations of ENT patients complained more and those older than 70 years complained less than the respective age groups of ENT patients treated at public hospitals. The mean incidence of ENT malpractice complaints was lowest in the Northern Jutland Region and highest in the Capital Region which was the most densely populated region. ENT departments at public hospitals receive complaints six times more frequently than ENT practicing clinics, even though the latter handle more patient contacts. The numbers of complaints and criticisms per specialist physicians at public hospitals were almost identical to those of specialist physicians serving at ENT practicing clinics.

CONCLUSION

An increasing trend in the number of the ENT malpractice complaints was found in the 1998-2008 period.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

[Judicial or administrative settlement of medical malpractice claims. Update on medical liability]

Settlement of medical malpractice claims was radically changed by the Kouchner Law that set up a rapid, effective system of indemnification. Victims can choose between conventional court proceedings and a non-judicial conciliation procedure. Choice between the two processes depends on the circumstances of the case.

Communicating the harmful effects of radiation exposure from medical imaging: malpractice considerations

Concerns about possible harmful effects of exposure to radiation arising from diagnostic radiologic procedures have existed in both the scientific and lay communities for many decades. There is, however, no question that the degree of concern over the past years has escalated to the "anxiety" if not the "fear" level. Potential exposure to radiation is not a new issue, but it is certainly a "hot" issue. Americans were exposed to more than six times as much ionizing radiation from diagnostic medical procedures in 2006 than they were in early 1980s. To what extent this increased exposure elevates the risk of genetic mutations and/or development of cancer is not known with any degree of certainty. The available data are subject to varying interpretations, often debatable and thus controversial. What should be communicated to the public? The medical and scientific communities must encourage public attention and discussion regarding radiologic imaging and associated radiation exposure. They must talk to the public sensibly about the uncertainty regarding the hazards of radiation exposure. Exposure to imaging involving radiation and the hazards related to such exposure has myriad medical/legal ramifications. There has never been a successful medical malpractice lawsuit that alleged development of cancer or genetic defects resulting from diagnostic x-ray examinations. However, there have been and continue to be lawsuits filed alleging soft tissue injury resulting from overexposure to diagnostic radiologic equipment and cancer caused by overexposure to radiation oncology equipment. It is quite likely that lawsuits alleging development of cancer arising from diagnostic imaging using standard levels of ionizing radiation will be forthcoming. How the courts will deal with these remains to be determined.

Understanding hospital professional liability claim costs

Managing the total cost of professional liability should be a top priority for health systems as professional liability costs will increase in coming years. The frequency of hospital professional liability claims has entered a period of modest growth. The severity of claims continues to grow, with claim severity projected to increase 4 percent in 2011. The combined effect of frequency and severity indicates HPL loss rates are expected to increase 5 percent in 2011.

Paid malpractice claims for adverse events in inpatient and outpatient settings

CONTEXT

An analysis of paid malpractice claims may provide insight into the prevalence and seriousness of adverse medical events in the outpatient setting.

OBJECTIVE

To report and compare the number, magnitude, and type of paid malpractice claims for events in inpatient and outpatient settings.

DESIGN AND SETTING

Retrospective analysis of malpractice claims paid on behalf of physicians in outpatient and inpatient settings using data from the National Practitioner Data Bank from 2005 through 2009. We evaluated trends in claims paid by setting, characteristics of paid claims, and factors associated with payment amount.

MAIN OUTCOME MEASURES

Number of paid claims, mean and median payment amounts, types of errors, and outcomes of errors.

RESULTS

In 2009, there were 10,739 malpractice claims paid on behalf of physicians. Of these paid claims, 4910 (47.6%; 95% confidence interval [CI], 46.6%-48.5%) were for events in the inpatient setting, 4448 (43.1%; 95% CI, 42.1%-44.0%) were for events in the outpatient setting, and 966 (9.4%; 95% CI, 8.8%-9.9%) involved events in both settings. The proportion of payments for events in the outpatient setting increased by a small but statistically significant amount, from 41.7% (95% CI, 40.9%-42.6%) in 2005 to 43.1% (95% CI, 42.1%-44.0%) in 2009 (P < .001 for trend across years). In the outpatient setting, the most common reason for a paid claim was diagnostic (45.9%; 95% CI, 44.4%-47.4%), whereas in the inpatient setting the most common reason was surgical (34.1%; 95% CI, 32.8%-35.4%). Major injury and death were the 2 most common outcomes in both settings. Mean payment amount for events in the inpatient setting was significantly higher than in the outpatient setting ($362,965; 95% CI, $348,192-$377,738 vs $290,111; 95% CI, $278,289-$301,934; P < .001).

CONCLUSION

In 2009, the number of paid malpractice claims reported to the National Practitioner Data Bank for events in the outpatient setting was similar to the number in the inpatient setting.

The impact of clinical child protection programs

PURPOSE

To follow up on child protection children after their discharge from hospital in order to assess efficiency of our child protection team (CPT) and collaboration of family and of Youth Welfare Agencies (YWA) with the clinical CPT.

METHODS

Collaboration of the family considering treatment and controls was documented. Questionnaires were sent to the involved social worker and collaboration with the YWA was analyzed.

RESULTS

From 2004 to 2008 57 children entered our child protection program. Clinical cooperation of the families and outcome was good overall. In 56 cases, an official information was sent to the YWA. In ten cases, the injuries were reported to the police which led to convictions in four cases. YWA installed further supervision and support in 53 patients. Cooperation of the families with the social workers was good in 50% of cases, ambivalent in 15% and not existent in 8%. Cooperation with the YWA was wearing.

CONCLUSION

Measurements initiated to protect children were efficient in 98%. While cooperation with the families and the social workers was good, cooperation with the institution of the YWA was wearing caused by discrepancies in understanding data protection acts and act of information. Here clarification is required to improve and simplify collaboration between all involved groups.

Cauda equina syndrome: a review of the current clinical and medico-legal position

Cauda equina syndrome (CES) is a rare condition with a disproportionately high medico-legal profile. It occurs most frequently following a large central lumbar disc herniation, prolapse or sequestration. Review of the literature indicates that around 50-70% of patients have urinary retention (CES-R) on presentation with 30-50% having an incomplete syndrome (CES-I). The latter group, especially if the history is less than a few days, usually requires emergency MRI to confirm the diagnosis followed by prompt decompression by a suitably experienced surgeon. Every effort should be made to avoid CES-I with its more favourable prognosis becoming CES-R while under medical supervision either before or after admission to hospital. The degree of urgency of early surgery in CES-R is still not in clear focus but it cannot be doubted that earliest decompression removes the mechanical and perhaps chemical factors which are the causes of progressive neurological damage. A full explanation and consent procedure prior to surgery is essential in order to reduce the likelihood of misunderstanding and litigation in the event of a persistent neurological deficit.