Finnish Patient Insurance Centre Research Articles

Patterns of malpractice claims and compensation after surgical procedures: a retrospective analysis of 8,901 claims from the Finnish patient insurance registry

BackgroundInvasive surgical procedures carry risk of harm to patients. In addition to avoidable harm, disparities between patient expectations and the outcome of a procedure may lead to patient injury claims. The follow-up of claims and compensation is an important entity for patient safety. The number of claims should be related to the surgical volume, so that a healthcare provider can benchmark with similar organizations and see if its trends are developing favourably or deteriorating. Our objective was to find out the claims and compensation rates due to surgery in an insurance-based system.MethodsData related to surgical claims and reference volume in the period 2011–2015 were collected from the claim register of the Finnish Patient Insurance Centre and benchmarking community register of Finnish operating departments. The data included age, gender, hospital, year of surgery, surgical code, and outcome of the claim.ResultsThere were 8,901 claims related to the corresponding reference group of 1,470,435 surgical procedures. The claims rate was 0.61% and compensation rate was 0.22%. Trends for claims and compensation rates decreased over the study period. In high volume procedures, a low compensation rate was detected for excision of tonsils and adenoids, Caesarean section and extracapsular cataract operations using the phacoemulsification technique. A high compensation rate was detected for primary prosthetic replacement of the hip and knee joints and decompression of spinal cord and nerve roots. Unreasonable injury (death or permanent deterioration of health) was compensated in 2.4 per 100,000 procedures.ConclusionsRegister data research in a no-fault patient insurance system revealed a claims rate of 6 per 1,000 procedures and compensation rate of 2 per 1,000 procedures. A decreasing trend in both rates over the study period was detected. Different surgical procedures exhibit varying claims and compensation rates.

Compensated Patient Injuries in the Treatment of Abdominal Aortic and Iliac Artery Aneurysms in Finland: A Nationwide Patient Insurance Registry Study

Patient injury claims data and insurance records provide detailed information on patient injuries. This study aimed to identify the errors and adverse events that led to patient injuries in vascular surgery for the treatments of abdominal aortic aneurysms (AAA) and iliac artery aneurysms (IAA) in Finland. The study also assessed the severity and preventability of the injuries. A retrospective analysis of Finnish Patient Insurance Centre's insurance charts of compensated patient injuries in the treatment of AAA and IAA. Records of all compensated patient injury claims involving AAA and IAA between 2004 and 2017 inclusive were reviewed. Contributing factors to injury were identified and classified. The injuries were assessed for their preventability by using the WHO Surgical Safety Checklist correctly. The degree of harm was graded by Clavien-Dindo classification. Twenty-six patient injury incidents were identified in the treatment of 23 patients. Typical injuries involved delays in diagnosis or treatment, errors in surgical technique or injuries to adjacent anatomic organs. Three (13.0%) patients died due to patient injury. Two deaths were caused by delays in diagnosis of ruptured abdominal aortic aneurysm (RAAA) and the third death was due to missed diagnosis of post-operative myocardial infarction. Retained foreign material caused injuries to two (8.7%) patients. One (4.3%) patient had a severe postoperative infection. Three (13.0%) patients experienced an injury to an adjacent organ. One patient had a bilateral and another a unilateral above-the-knee amputation due to patient injury. Three injuries were considered preventable. Most harms were grade IIIb Clavien-Dindo classification in which injured patients required a surgical intervention under general anesthesia. Compensated patient injuries involving the treatment of AAA and IAA are rare, but are often serious. Injuries were identified during all stages of care. Most injuries involved open surgical procedures.

Investigating errors in medical imaging: medical malpractice cases in Finland

ObjectiveThe objectives of the study were to survey patient injury claims concerning medical imaging in Finland in 1991–2017, and to investigate the nature of the incidents, the number of claims, the reasons for the claims, and the decisions made concerning the claims.Materials and methodsThe research material consisted of patient claims concerning imaging, sent to the Finnish Patient Insurance Centre (PVK). The data contained information on injury dates, the examination code, the decision code, the description of the injury, and the medical grounds for decisions.ResultsThe number of claims included in the study was 1054, and the average number per year was 87. The most common cause was delayed diagnosis (404 claims, 38.3%). Most of the claims concerned mammography (314, 29.8%), radiography (170, 16.1%), and MRI (162, 15.4%). According to the decisions made by the PVK, there were no delays in 54.6% of the examinations for which claims were made. About 30% of all patient claims received compensation, the most typical reason being medical malpractice (27.7%), followed by excessive injuries and injuries caused by infections, accidents and equipment (2.7%).ConclusionPatient injury in imaging examinations and interventions cannot be completely prevented. However, injury data are an important source of information for health care. By analysing claims, we can prevent harm, increase the quality of care, and improve patient safety in medical imaging.

Are women more susceptible than men to iatrogenic inferior alveolar nerve injury in dental implant surgery?

An over-representation of women in dental implant-related inferior alveolar nerve injuries (IANIs) is recognized in the literature but has not been investigated. Therefore, a nationwide retrospective register study was conducted to analyse how IANIs compare with other implant-related complications (infection, implant malposition, lack of bone at implant site, mechanical damage, or failed osseointegration) separately in women and men. Financially compensated malpractice claims related to dental implant surgery were collected from the Finnish Patient Insurance Centre for the years 1997—2013, while the total number of nationally placed implants was ascertained from the implant register held by the Finnish Institute for Health and Welfare. In the 242 complications, the following were analysed: age of subject, absolute risk for complication, and aetiological factor of IANI. Statistical tests applied include Mann–Whitney U-test, Chi-squared test, and Fisher’s exact test. Women sustaining IANI were more likely older than those having infection, mechanical damage, or failed osseointegration (P<0.05), while no significant differences emerged in men. Women were more likely at risk for IANI (P<0.01) or implant malposition (P<0.05) than men. The results support earlier propositions that women are more vulnerable than men to iatrogenic IANI.

Patient injuries in the treatment of superficial venous insufficiency registered in Finland between 2004 and 2017.

This study aimed to identify the unintended incidents that led to patient injuries (PIs) in the treatment of superficial venous insufficiency (SVI). PI claims filed with the Finnish Patient Insurance Centre between 2004 and 2017 involving SVI were reviewed. Factors contributing to PI were identified and classified. Eighteen (13.2%) of 136 compensated PIs in the specialty of vascular surgery were related to SVI. Only 4.7% of 383 SVI claims were compensated. The incidence of PIs was 9.9 per 100 000 patients. Fifteen patients had open surgery (83.3%) and three (16.7%) endovenous treatment. Two (11.1%) patients had necrotising fasciitis, four (22.1%) had deep vein injuries and two (11.1%) had a permanent nerve injury. Two (11.1%) patients had retained endovenous material that required surgical removal. PIs were identifiable during all stages of care, perioperative injuries related to open surgery being the most common.

Patient Injuries in Treatment of Peripheral Arterial Disease in Finland: Review of National Patient Insurance Charts

Patient injury claim data and insurance records constitute detailed sources of information on patient injuries and their contributing or causal factors. This study aimed to identify the unintended incidents that lead to patient injuries in vascular surgery in the treatment of peripheral arterial disease (PAD) in Finland. The records of all accepted patient injury claims involving PAD between 2004 and 2017 inclusive were obtained from the nationwide Finnish Patient Insurance Centre registry and were reviewed. Factors contributing to injury were classified by patient careflow. Sixty-nine patient injury incidents were identified in 60 treated patients with PAD. Sixteen injuries (23.2%) were related to outpatient or preoperative care. Twenty-seven injuries (39.1%) were caused by incidents in performing open or endovascular procedures, and 26 injuries (37.7%) were related to postoperative care. Delay in treatment affected 11 (18.3%) patients. Incidents involving surgical technique were identified in the treatment of 13 (21.7%) patients. Retained foreign material caused injuries to four (6.7%) patients. Five (8.3%) patients suffered from postoperative hemorrhage and eleven (18.3%) from infection damage. Delay in treatment resulted in two major amputations. Technical problems in bypass operations led to the loss of the bypass graft and to reoperation. Three nerve injuries led to permanent disability. One (1.7%) patient died because of fatal postoperative bleeding after being discharged from the hospital. Compensated patient injuries in the treatment of PAD are rare. Injuries occur during all stages of care and are caused by both surgical system procedural failures and common complications.

Did malpractice claims for failed dental implants decrease after introduction of CBCT in Finland?

To examine the role of cone beam computed tomography (CBCT) in preventing failures in implant treatment. We hypothesize that the number of malpractice claims related to dental implant treatment would decrease after the first CBCT device came available in 2002 in Finland. Data concerning malpractice claims related to dental implant treatment during the years 1997-2011 were collected from the Finnish Patient Insurance Centre (N = 330 subjects). We selected the cases that might have benefitted from the use of CBCT examination. These cases (n = 131) led to financial compensation due to permanent inferior alveolar nerve injury, improper implant position, or insufficient amount of bone for the implant. The annual total number of inserted dental implants, CBCT devices, and CBCT examinations in Finland were drawn from the national registers and used to estimate the impact of CBCT in preventing treatment failures. The most common reason for all failures (n= 268 implants) was an improper implant position (46.3%). The most common area of malpractices was upper front teeth (34%). We have noticed a fall in the rate of compensable malpractice cases concerning implant failure, simultaneously with CBCT technology emerging on the market. There may be an association between the increasing availability of CBCT equipment and the reducing frequency of compensable malpractice claims. It is possible that the use of CBCT may result in fewer compensable malpractice claims.

Iatrogenic patient injuries in otology during a 10-year period: review of national patient insurance charts

Objective: To assess patient injury characteristics and contributing factors in otology.Methods: Data on the accepted patient-injury claims involving otorhinolaryngology (ORL), closed between 2001 and 2011, from the Finnish Patient Insurance Centre registry was retrieved. We included all injuries concerning otology, with evaluation and classification of their causes and types.Results: During the 10-year study period, a total of 44 claims were accepted as compensated patient injuries in otology. From a total of 233 patient injuries in all ORL, this amounted to 19%. In outpatient care, occurred 12 (27%) injuries and in surgical procedures 32 (73%). Five (11%) patients were children. Errors in surgical technique were identified as the primary cause of the injury in 22 (69%) operation-related cases. Failure to remove all auricular tampons or packing in postoperative control was a contributing factor in 4 (13%) injuries, a facial nerve was damaged in 9 (28%) operations, and in 12 (38%) patients, the injury resulted in severe hearing loss or deafness. Six patients (21%) needed one or more re-operations related to the injury, of which two were due to an incomplete primary operation.Conclusion: Typical compensated patient injuries in operative otology resulted from common complications of common operations in high volume centres.

Patient injuries in operative rhinology during a ten-year period: Review of national patient insurance charts.

To assess factors contributing to patient injuries in operative rhinology. Data of the accepted patient injury claims involving operative rhinology, between the years 2001 and 2011, were obtained from the Finnish Patient Insurance Centre registry. Two senior otolaryngologists analysed and evaluated the injury mechanisms. Analysis and classification of factors contributing to patient injuries. During the ten-year study period, there were 67 patient injuries in operative rhinology, comprising 36% of all patient injuries in otorhinolaryngologic surgery. The majority (78%) of patients were treated in university or central hospitals and almost all (90%) by fully trained otolaryngology specialists. The factors contributing to the injuries were errors in surgical technique, like lesions to the orbit, skull base and meninges, and adjacent nerves, as well as mistakes with removable packings left in situ. Nearly half of the patients had undergone endoscopic sinus surgery. One patient died because of bleeding from the intracranial artery. Fourteen patients (21%) needed a re-operation due to the injury. Patient injuries in rhinology were caused by typical complications of common operations performed by otorhinolaryngology specialists. The increased volume of endoscopic sinus surgery was evident also in patient injuries.

Malpractice claims related to tooth extractions.

The aim of this study was to analyze malpractice claims related to tooth extractions in order to identify areas requiring emphasis and eventually to reduce the number of complications. We compiled a file of all malpractice claims related to tooth extractions (EBA code) between 1997 and 2010 from the Finnish Patient Insurance Centre. We then examined the data with respect to date, tooth, surgery, injury diagnosis, and the authority's decision on the case. The material consisted of 852 completed patient cases. Most of the teeth were third molars (66%), followed by first molars (8%), and second molars (7%). The majority of claims were related to operative extraction (71%) followed by ordinary extraction (17%) and apicoectomy of a single-rooted tooth (7%) or multi-rooted tooth (2%). The most common diagnosis was injury of the lingual or inferior alveolar nerve. According to the authority's decision, the patient received compensation more often in cases involving a third molar than other teeth (56 vs. 46%, P < 0.05). The removal of a mandibular third molar was the basis for the majority of malpractice claims. To reduce the numbers of lingual and inferior alveolar nerve injuries, the removal of mandibular third molars necessitates recent and high-quality panoramic radiograph, preoperative assessment of the difficulty of removal, and consciousness of the variable anatomical course of the lingual nerve.

Dental treatment injuries in the Finnish Patient Insurance Centre in 2000–2011

Objective The Patient Insurance Centre in Finland reimburses patients who sustained injuries associated with medical and dental care without having to demonstrate malpractice. The aim was to analyse all dental injuries claimed through the Patient Insurance Centre over a 12-year period in order to identify factors affecting reimbursement of claims. Methods This study investigated all dental patient insurance claims in Finland during 2000–2011. The injury cases were grouped as (K00–K08) according to the International Classification of Diseases (ICD-10). Calendar year, claimant’s age and gender, dental disease group and health service sector were the explanatory factors and the outcome was the decision of a claim. Multiple logistic regression modelling was used in the statistical analyses. Results The total number of decisions related to dental claims at the PIC in 2000–2011 was 7662, of which women claimed a clear majority (72%). Diseases of the pulp and periapical tissues (K04) and dental caries (K02) were the major disease groups (both 29%). Of the claims 40% were eligible for reimbursement, 27% were classified as insignificant or unavoidable injuries and 32% were rejected for other reasons. The proportion of reimbursed claims declined during the period. Patients from the private sector were more likely to be eligible for compensation than were those from the public sector (OR = 1.89, 95% CI = 1.71–2.10). Conclusions The number of dental patient insurance claims in Finland clearly rose, while the proportion of reimbursed claims declined. More claims received compensation in the private sector than in the public sector.

Severe Complications of Laparoscopic and Conventional Appendectomy Reported to the Finnish Patient Insurance Centre.

Appendectomy is considered a safe operation, the related complications being minor. Negative exploration is an accepted procedure to avoid complications of appendicitis. Treatment with antibiotics is under debate as a primary treatment for appendicitis. The aim of this study was to collect and analyze detailed information on complications and morbidity related to appendectomy using the information of the nationwide Patient Insurance Association (PIA) database and to study the incidence of patient claims and compensated injuries related to appendectomy in Finland. Patients' claims from 1990 to 2010 were collected from the PIA register. Complications were classified using the accordion severity grading system. Severe complications were selected for more detailed analyses. Laparoscopic and open surgeries were compared. Factors related to compensated claims were assessed. For statistical analysis, Fisher's exact test, logistic multivariate regression, and the Mann-Kendall function were used. Appendectomy complications leading to a patient insurance claim in Finland are rare (0.2 %). The rate of patients' claims after laparoscopic surgery was higher than after open surgery (p < 0.001), but the rate of compensated claims was equal. During the study period, complications after laparoscopic procedures more often led to additional surgery or organ failure (p = 0.03). Of the patients with a compensated injury, only 57 % had appendicitis. Preoperative computed tomography was used in only 6 % of these cases. Patient injuries and claims regarding severe complications after appendectomy are rare. The complications related to laparoscopic appendectomy were more severe than those of open surgery.

Open Mesh Repair for Inguinal Hernia is Safer than Laparoscopic Repair or Open Non-mesh Repair: A Nationwide Registry Study of Complications.

Inguinal hernia repair is the most common elective procedure in general surgery. Therefore, the number of patients having complications related to inguinal hernia surgery is relatively large. The aim of this study was to compare complication profiles of inguinal open mesh (OM) hernioplasties with open non-mesh (OS) repairs and laparoscopic (LAP) repairs using retrospective nationwide registry data. The database of the Finnish Patient Insurance Centre (FPIC) was searched for complications of inguinal and femoral hernia repairs during 2002-2010. Complications of OM repairs were compared to complications of OS repairs and LAP repairs. Over 75 % of all inguinal hernia procedures during the study period in Finland were OM hernioplasties. FPIC received 245 complication reports after OM repairs, 40 after OS repairs, and 50 after LAP repairs. Reported complications were significantly more severe after LAP and OS repairs than OM surgery (p<0.001). Visceral complications (p<0.001), deep infections (p<0.001), and deep hemorrhagic complications (p<0.001) were overrepresented in the LAP group. In the OS group, visceral complications (p<0.001), recurrences (p<0.001), and severe neuropathic pain (p<0.001) predominated. LAP and OS repairs of inguinal hernia were associated with more severe complications than open surgery with mesh in this study.

Surgery-related complications of ventral hernia reported to the Finnish Patient Insurance Centre

Our aim was to evaluate the incidence and type of severe complications in adult primary and incisional ventral hernia surgery reported to the National Patient Insurance Centre in Finland during 2003-2010. The Finnish National Patient Insurance Centre covers the whole country and handles financial compensation for patients' injuries without proof of malpractice. All the claims concerning ventral hernioplasties in the Centre between the years 2003 and 2010 were retrospectively analyzed. The annual numbers of primary and incisional ventral hernioplasties in Finland were obtained from the National Hospital Discharge Register. During the study years, 25,738 ventral hernia operations were performed and 127 claims from the whole country were reported to the Patient Insurance Centre. Overall rate of claims was 4.9/1000 hernia procedures. For primary hernias, 16,243 ventral hernioplasties (817 laparoscopic, 15,426 open) were performed and 41 complications were reported. The most common complication was infection (n = 28, 68%) followed by pain and hernia recurrence (n = 6, 15% in both), large hematoma (7%), bowel lesion (5%), urological injuries (2%), or severe bleeding (2%). In incisional hernioplasties, the rate of claims was 9.1/1000 operations (9495 operations, 86 claims). The most common complication reported was infection (n = 42, 49%) followed by hernia recurrence in 25 cases (29%) and bowel lesion in 24 cases (28%). Major complications (n = 15, 17%) consisted mainly of bowel lesions in laparoscopic operations. There was significantly more claims after laparoscopic than open hernioplasties (p = 0.001). The claims for financial compensation for injuries related to primary and incisional hernioplasties are quite uncommon. Major complications, though comparatively rare, are significantly more common after laparoscopic operations.

Role of orchiectomy in severe testicular pain after inguinal hernia surgery: audit of the Finnish Patient Insurance Centre

Testicular ischemia and necrosis are uncommon complications after inguinal hernioplasty. Our aim was to evaluate the incidence of severe urological complications related to adult inguinal hernia surgery in Finland with special reference to orchiectomy in relieving intractable chronic testicular pain. All urological complications related to inguinal hernia surgery during 2003-2010 were analysed from the Finnish Patient Insurance Centre. The patients with intractable chronic scrotal or testicular pain that resulted in orchiectomy were re-evaluated after a median follow-up of 7 years (range 2-15 years). The operative factors related to chronic testicular pain and atrophy were analysed using multiple regression analysis. Altogether 62 urological complications (from 335 litigations) were recorded from 92,000 inguinal hernia operations. The distribution of claimed urological complications consisted of 34 testicular injuries, ten bladder perforations, seven massive scrotal haemorrhage or 11 miscellaneous injuries. Seventeen atrophic testes were left in situ and 17 (six early < 7 days, 11 late > 8 days) orchiectomies were performed due to necrosis or chronic testicular pain syndrome. In the conservative group of moderate scrotal or testicular pain (n = 17), all patients had late pain symptoms (>8 days), but pain was not so severe that orchiectomy was attempted. Using a multivariate analysis, postoperative infections were associated with chronic testicular or scrotal pain and atrophy, but hospital status, surgeon's training level, laparoscopic or open operation, type of hernia or use of mesh did not correlate with testicular injuries. During follow-up, 11/17 (65%) patients with orchiectomy were free of testicular pain. Urological injuries form one-fifth of the major complications after inguinal hernioplasty. Orchiectomy appears to help the majority of patients with severe testicular pain syndrome.

Analysis of systemic and local odontogenic infection complications requiring hospital care

Analysis of systemic and local odontogenic infection complications requiring hospital care. All cases of odontogenic infections requiring hospital care, which were adjudicated in the Finnish Patient Insurance Centre during 2000-2003, were analysed. Patient characteristics, and the course and outcome of infection were reviewed. The study material consisted of 35 patient cases; 15 male, 20 female; mean age 38.4 (16-67) years. The mean length of hospital stay was 14.8 (2-81) days. Nine patients required intensive care for mean 6.2 (2-19) days. Twenty-five (71%) patients developed local infection complications with cellulitis and abscess formation, and 10 (29%) patients a generalised or metastatic infection complication. The length of hospital stay among patients with systemic complications was longer than with local complications, 30.2 (2-81) days vs. 8.0 (2-34) days (p=0.0144). All patients with local complications survived but three of the 10 patients with systemic complications died. Medically compromised patients with underlying disease developed more often systemic infection complications than previously healthy patients (p=0.0028). Medically compromised patients appear more susceptible to systemic rather than local infection complications with a need for significantly longer hospital stay and with an increased risk for fatal complications.