Current Medicolegal Climate Research Articles

Updates in medical malpractice: an otology perspective.

Most surgeons at some point are involved in a medical malpractice case. There has been an increase in the number of manuscripts that analyse malpractice databases and insurance claims, as well as commentaries on the current medicolegal climate recently. This manuscript broadly reviews articles of interest to all providers and then focuses on malpractice in otology. Medical malpractice articles (particularly topics related to otologic surgery published within the last 1-2 years) were searched. The growing body of literature can be divided into the themes of general negligence, mitigating injuries and the use of clinical practice guidelines in the courtroom as guidance for expert witnesses. Recent findings suggest that the frequency of malpractice claims may be decreasing. Hearing loss and facial nerve injury are the most common injuries associated with otologic surgery. These injuries can be costly when negligence is found. Clinic practice guidelines are slowly being used as evidence in the courtroom and there are established guidelines that an expert witness must follow should a surgeon be called to give testimony.

PPO.63 Patient safety in the nhs: the role of the coroner rule 43 in improving maternal safety

BackgroundThe UK CMACE Report 2006–2008 Top Ten Recommendations #9 and #10 highlighted the importance of investigating Serious Incidents and maternal death to establish an integrated safety-focused culture. With the increasing...

Medical Malpractice While My Guitar Gently Weeps

Medical Malpractice While My Guitar Gently Weeps

Medico-legal issues in obstetric anesthesia: what does an obstetrician need to know?

Obstetric anesthesia has become a recognized subspecialty of anesthesiology and an integral part of practice of most anesthesiologists. Perhaps no other subspecialty of anesthesiology provides more personal gratification and clinical challenges than the practice of obstetric anesthesia. However, in addition to clinical challenges obstetric anesthesia is laden with medico-legal liability. This review article attempts to highlight the influence of the current medico-legal climate on the practice of obstetric anesthesia. All articles relevant to the subject of this investigation were retrieved from a Medline search. Obstetric anesthesiologists are frequently named (besides obstetricians) in claims involving bad neonatal outcomes. Obstetric anesthesia is also the most common subspecialty of practice to be ceased due to medico-legal concerns. Good perioperative evaluation of all patients, detailed review of patient's medical records, and constant vigilance can decrease the incidence of complications and subsequently medico-legal issues.

The Case for Standardisation of the Management of Gallstones Spilled and not Retrieved at Laparoscopic Cholecystectomy

This observational study was carried out to establish how surgeons performing laparoscopic cholecystectomy currently deal with the issue of spilled gallstones. A questionnaire was circulated amongst laparoscopic surgeons attending the annual conference of the Association of Laparoscopic Surgery of Great Britain and Ireland in November 2006. Eighty-two surgeons completed the questionnaire. Only half of surgeons inform patients when gallstones are spilled. Less than 30% of surgeons inform general practitioners (GPs) of this complication, when it occurs. Less than a quarter of surgeons include this information in the consent literature provided to patients. We recommend that trusts review their policy towards spilled stones either by local audit or adopt the guidance given by the UK Healthcare Commission. While some surgeons feel informing patients and GPs may unnecessarily heighten anxiety from an uncommon complication, our review of the literature suggests this position is not tenable in the current medicolegal climate.

The Influence of the Current Medicolegal Climate on New South Wales Anaesthetic Practice

A survey was posted to all New South Wales and Provisional Fellows of the Australian and New Zealand College of Anaesthetists to assess the influence of the current medicolegal climate on their anaesthetic practice. Information collected included demographics, opinions regarding the current medico-legal climate, medical defence organizations, and the implications for anaesthetic practice. The response rate was 78% (640/820). Nearly all (95.3%) were concerned about the current medical indemnity crisis and 80.5% felt concerned about the financial security of medical insurers. Of all these respondents 23.6% had personal experience of litigation and 73.6% expected to have a claim made against them during their career: Respondents spent an average of 8.3% of their gross annual income on medical insurance premiums and 47.2% are concerned about the viability of their practice given the rising costs of medical insurance. Obstetric anaesthesia was the most common area of practice to be ceased due to medicolegal concerns. In the next two years, 20.2% of obstetric anaesthetists who responded intend to cease practice. In the past two years, 3.1% of respondents retired due to their litigation concerns, while 12.8% (average age 56.7y) are intending to retire in the next two years for the same reasons. Changes to the conduct of the preoperative consultation were common. Other changes to practice included more thorough documentation of complications (50.8%) and a strong reluctance to perform neuraxial blocks (54%). This survey suggests that anaesthetists are concerned about the current medicolegal climate and as a result, some are retiring earlier and giving up high-risk areas of practice.

Women with low-grade abnormalities on Pap smear should be referred for colposcopy.

To assess cytological, colposcopic and histological outcomes in women referred to a teaching hospital dysplasia clinic with low-grade changes on screening Pap smear. Analysis of a computerised database. Repeating the Pap test was of little value. Fifteen percent of women with low-grade changes on the referral smear had biopsy proven high-grade change. There was little difference in biopsy proven high-grade change in women referred with an 'abnormal smear of uncertain significance' (23%) or 'an abnormal smear of uncertain significance-possible high-grade change' (24%). Given these findings and the current medico-legal climate, immediate referral of women with low-grade changes on routine cytology is indicated, and seems a safer option than the more conservative approach of a repeat smear in 6 or 12 months. Further study of the usefulness of separating smears of uncertain significance into high-grade and low-grade categories is warranted. Consumer input into recommendations for management of Pap smear abnormalities is required.

Should central venous catheters be used to drain pleural effusions? Authors' response

We would like to thank MacDuff and Grant [1], as well as the many others who accessed it, for their interest in our article [2] on using central venous catheters for pleural drainage. We started using this technique about 5 years ago with the aim of achieving better patient comfort without compromising on adequate pleural drainage. We did not at that time have access to the specific chest drainage systems mentioned by MacDuff and Grant. While we agree that the central venous catheters we describe are not specifically designed for the purpose of pleural drainage, they are made of biologically inert materials with a long track record of intravenous use. We have not modified them before placement. To minimize the risk of complications at insertion, we were selective in our choice of patients and we monitor these patients closely from the safety and efficacy points of view. We share MacDuff and Grant's views on the need to practice safely in the current medico-legal climate. Our management is frequently influenced by the need to be seen to be medico-legally correct. This, however, has probably resulted in the increased per-patient care cost. We find this to be especially true in the use of specially designed equipment whose usage levels are fairly low. In the case of the two catheter systems mentioned by MacDuff and Grant, the prices quoted in Singapore are between eight and 10 times higher than the cost of the single lumen central lines described. We intuitively agree that these catheters with the multiple drainage lumens have a lower risk of catheter blockage compared with the central venous catheters. We are not, however, aware of any published literature that ascertains this. We have not experienced any catheter blockage with the catheters we use despite seeing fibrinous material in the drainage bag. We have been caught by surprise at the number of readers who accessed this article, perhaps because this is an Open Access article. A number of these readers may work in financially stretched healthcare systems. We hope that by sharing our experience this technique may prove useful when it is difficult to procure specially designed sets, either because they are expensive or because they are not readily available. We caution readers, however, to select their patients carefully and to monitor the efficacy of the placement of these catheters. We do not advocate using this technique for the drainage of haemothoraces or empyemas.

Current practice regarding re-use of trauma instrumentation: results of a postal questionnaire survey

A total of 248 Orthopaedic Units in the UK were surveyed following two newspaper articles about broken drill bits being retained in patients’ bones. Questions were asked about re-use of drills, guide wires and taps, as well as about informing patients when drill bit fragments were left in situ during trauma surgery. The response rate was 79.0%. The majority of hospitals are not using new drill bits for each case nor new guide wires. In the current medicolegal climate, the fact that the majority of consultants are informing patients soon after surgery that a drill bit has fragmented in their bone is applauded.

Fison's Retinal Detachment Surgery

This volume, a compilation of a lecture series given in Singapore in 1975 by Lorimer Fison on retinal detachment surgery, is an updated version of the original text published in 1977. The book is intentionally written in the style of a lecture rather than in typical textbook style. Its stated purpose is to simplify the problems of retinal detachment to enable the nonsubspecialty surgeon ("the occasional retinal detachment surgeon") to obtain good results in a majority of cases. This goal, of course, may be at odds with the current medicolegal climate in the United States, but it is clearly useful to the general ophthalmic surgeon in a third-world country who may be many miles from the nearest vitreoretinal surgeon. As in the first edition, this book is schematic rather than encyclopedic in approach. The wording is simple and clear and each chapter is summarized in a brief introduction. Several terms

Antibiotics and Colon Surgery-Reply

<i>In Reply</i>.—I confess that I fail to discern a substantive disagreement between Dr Menaker's practices and the position advocated in the editorial. Dr Menaker administers intravenous (IV) ampicillin, a cephalosporin, or chloramphenicol intraoperatively and postoperatively to his patients undergoing colorectal operations; in six of the 100 patients he described a wound infection developed.¹ Whether antibiotics should be administered parenterally or orally is one of the open, lively issues of current surgical discussion identified in the editorial. But the major editorial point was that the evidence from numerous controlled clinical studies was now sufficiently clear that all patients having a colorectal operation today should receive antibiotics by one route or another. The evidence in favor of antibiotics is so overwhelming that, in my view, this is no longer a moot issue.² While I share Dr Menaker's general concern about our current medicolegal climate, in my mind that climate

Postoperative facial paralysis: The otologist's dilemma

AbstractThis paper deals with the problems of postoperative facial paralysis complicating middle ear and mastoid surgery. The anatomy of the tympanic and mastoid portions of the facial nerve is discussed, and facial nerve anomalies, dehiscences and variations are described. Helpful landmarks for locating the facial nerve in the diseased and congenitally abnormal temporal bone are reviewed. A discussion of the etiology of immediate and delayed postoperative facial paralysis is presented, together with four illustrative case histories. Management of the problem is based upon accurate documentation of immediate versus delayed paralysis, and may vary from a period of watchful waiting to medical or surgical therapy.The modern otologic surgeon must be thoroughly familiar with the anatomy of the facial nerve within both the normal and the abnormal temporal bone. This familiarity is based upon the quality of his training, the scope of his surgical experience, continuing medical education, and upon an honest appraisal of his own capabilities. The current medicolegal climate dictates that it is better to refer a problem case than to suffer a bad result. This is likely to be the situation in the forseeable future.