Medical Misadventure Research Articles

Medical Malpractice Risk Assessment in Plastic Surgery

INTRODUCTION: In a society where litigation has become almost conventional, plastic surgeons are particularly vulnerable to malpractice claims as their practices consist of primarily elective procedures and frequently patients with unrealistic expectations. Previous authors evaluated the cumulative risk of being sued by medical specialty and found that physicians performing surgical procedures made up the top five physicians types who faced a malpractice claim annually (1). METHODS: In this study, we expanded the data set of previous studies (1, 2) with characterization of malpractice risk assessment specific to the field of plastic surgery. Data from a medical insurance association from 1985 to 2010 was analyzed for 25 medical specialties. RESULTS: During this period, 256,225 closed claims were identified, of which 9,312 (3.6%) represented plastic surgery claims. Of the $16 billion paid for all medical specialties combined, the total indemnity payment for liability claims for plastic surgery procedures was $297 million (1.86%). Physicians performing these plastic surgery procedures were frequently male (74.5%), between the ages of 35 and 54 (70.1%), and of solo practice settings (62.7%). It is important to note that the physicians performing these plastic surgery procedures were not necessarily all board-certified plastic surgeons. Physicians performing plastic surgery procedures ranked 8th in the number of claims filed and 13th in total amount of indemnity paid, which is 44.1% less than the overall average of other medical specialties. A trend analysis of plastic surgery claims in 5-year intervals demonstrated an initial increase during the 1985-1995 decade, but has since been on a steady decline. The 10 most prevalent medical misadventures in plastic surgery procedures were evaluated; “improper performance of a procedure” was the most common (48.2%). The top procedures named in these claims included those of the skin, nose, eyelid, and breast. CONCLUSION: Although claims associated with plastic surgery procedures constitute a small fraction of other specialties, these are still detrimental to the viability of our specialty. Plastic surgeons can protect themselves by properly obtaining informed consent, being familiar with malpractice insurance policies, and continuing to provide the standard of care. Comparisons of procedures performed by board-certified plastic surgeons and non-plastic surgeons will be the focus of our future research assessments.

Abstract P72: Medicolegal Characteristics of Cardiac Catheterization Litigation

BACKGROUND AND AIMS: Cardiac catheterizations have become an integral part of medical care; however, there have been few assessments of the pattern of medicolegal cases that involve cardiac catheterizations. This study reviews the patterns of liability and medical outcomes in cases involving cardiac catheterization litigation. METHODS: Legal case opinions were obtained from LexisNexis Academic; case characteristics, litigation outcomes, and medical outcomes were identified. Additionally, data was collected from the Physician Insurers Association of America (PIAA), which is an Association that maintains a data registry of medical professional liability claims. RESULTS: Between 1985 and 2009, the PIAA registry documented 1361 closed coronary angiography claims. The medical specialty of Cardiovascular Disease was involved in 699 of these cases with other specialties such as internal medicine, CT surgery, general surgery being involved in the remaining cases. Of these claims, 36% (492 of 1361) were voluntarily dismissed, 25% (337 of 1361) were settled before litigation, 16% (215 of 1361) were not prosecuted, and 11% (154 of 1361) were involuntarily dismissed. The most common alleged error was for improper performance (482 of 1361) followed by no medical misadventure (316 of 1361). Of the 116 cases reviewed through LexisNexis, only 30% (35 of 116) were judged in the patients’ favor. Litigation against physicians occured in 90.5% (105 of 116) of cases with judgments in favor of the patients in 29.5% (31 of 105) of cases. Death as outcome was present in 42 cases. In these claims, the physicians were more likely to be sued (95%–40 of 42) and the judgment was more likely to be in the patients’ favor (40.5%–17 of 42). CONCLUSION: In litigation related to cardiac catheterizations, the majority of cases are due to medical malpractice and physicians are sued in a high percentage of those cases. It is important that cardiologists recognize these patterns of litigation as this may impact and improve the processes of care. However, physicians in other fields should be aware of these findings as specialties outside of cardiology were involved in almost half of all litigation cases.

Robert Garrett, Tasmanian penal colony surgeon: alcoholism, medical misadventure and the penal colony of Sarah Island

Robert Garrett emigrated from Scotland to Van Diemen's Land (now Tasmania) in 1822. Within a few months of arrival he was posted to the barbaric penal colony in Macquarie Harbour, known as Sarah Island. His descent into alcoholism, medical misadventure and premature death were related to his largely unsupported professional environment and were, in many respects, typical of those subjected to this experience.

Guest Family Physician Commentaries

As family physicians, we are very committed to providing the highest quality of care to our patients. Our primary focus is to understand patients’ unique needs and expectations and to address them accordingly. Unfortunately, living in a litigious society, we are not protected from liability claims. A liability claim does not equate with suboptimal care. Flannery et al 1 offers insight about the most common liability risks experienced by family physicians. Being aware of these risks provides better understanding of risk management and liability prevention. Flannery et al 1 report a comprehensive summary of data, collected by the Physician Insurers Association of America, which is not all inclusive of past claims but is probably representative of the nature of the claims affecting family physicians. It was interesting to note that family physicians were ranked third of the reported 28 specialties based on number of claims files against them, right after obstetrics/gynecology and internal medicine and above general surgery and orthopedics. The most prevalent “medical misadventure” was a diagnostic error, led by acute myocardial infarction and followed by breast cancer, appendicitis, and then lung and colon cancers. It is not surprising that coronary artery disease is the most commonly cited diagnostic error given the critical nature of the problem, atypical presentations, and being the leading cause of morbidity and mortality in our society. Cancer screening and early diagnosis is also a frequently encountered problem, so following strictly the US Preventive Services Task Force’s guidelines is critical for better patient care as well as malpractice prevention. Against the popular belief that procedurally oriented providers are more prone to malpractice claims, the most prevalent procedure in this database was “diagnostic interview and evaluation.” This data emphasizes once again the importance of establishing rapport with patients and their families and the value of open communication. Patients have a right to be equal partners in decision making and understanding their options for diagnosis and management. If the patient and the provider reach common ground, both compliance and outcomes improve. Highquality patient care and risk management principles are congruent and stem from effective doctorpatient communication.

Lessons Unlearned, Education Forfeited: Military Hygiene Enters the 21st Century

ABSTRACTObtaining and maintaining a military force hearty enough for the trials of campaign and combat is the concern of military hygiene. It has been a challenge for governments and commanders for centuries. Empirical practices in recruiting, training, and maintaining service members gave way to more scientific, evidenced-based practices of the 18th century, and the research-driven, laboratory-proven methods of the late 19th century. As science made military medicine predictable, it widened the intellectual and professional gap between commander and medical officer, weakening trust and hindering communication. It also distanced the medical officer from the more mundane health and fitness concerns of service members by transforming military hygiene into military preventive medicine. Medical misadventures consequent to this state of affairs continue into the 21st century and will remain until a philosophical and educational shift in the value of military hygiene occurs.

Urological Malpractice: Analysis of Indemnity and Claim Data From 1985 to 2007

The possibility of a medical malpractice lawsuit is present in the practice of modern day medicine. A basic knowledge of trends, monetary values and types of claims involved in urological litigation is beneficial to the practicing surgeon. Cumulative analysis of claims data from 1985 to 2007 from more than 20 member companies of the Physician Insurers Association of America was performed. A total of 28 medical specialties are represented in 230,000 claims. An analysis of urological claims with regard to other specialties, trends, and most prevalent and types of procedures was performed. Urology ranks 12th of 28 in the number of claims reported (5,577) and monies paid, totaling $285 million during 22 years. The average urology paid claim from 1985 to 2007 was $174,245, which is less than the average of all groups ($204,268). In 2007 the average indemnity paid was $227,838, which is an increase from $176,213 in 1997. The 2 most prevalent medical misadventures were improper performance and diagnostic errors, which accounted for 51% of all of the claims. Urology tends to be at or below average compared to other medical specialties in regard to total claims, total monies paid and average monies paid during the last 23 years. From 1997 to 2007 the average indemnity paid increased by 23%. Improper performance, diagnostic errors and failure to monitor cases resulted in the most lawsuits. In those groups malignancy of the prostate, testis and kidney appeared consistently. Continued analysis and education on medical litigation in urology can aid in increased awareness and possibly improved care for patients in the future.

A case control study of differences in non-work injury and accidents among sawmill workers in rural compared to urban British Columbia, Canada

BackgroundUsing a cohort of British Columbian male sawmill workers, we conducted a nested case-control study of the impact of rural compared to urban residence as well as rural/urban migration patterns in relation to hospitalization for non-work injury. We postulate that for many types of non-work injuries, rates will be higher in rural communities than in urban ones and that rates will also be higher for workers who migrate from urban to rural communities.MethodsUsing conditional logistic regression, univariate models were first run with each of five non-work injury outcomes. These outcomes were hospitalizations due to assault, accidental poisoning, medical mis-adventure, motor vehicle trauma, and other non-work injuries. In multivariate models marital status, ethnicity, duration of employment, and occupation were forced into the model and associations with urban, compared to rural, residence and various urban/migration patterns were tested.ResultsUrban or rural residence and migration status from urban to other communities, and across rural communities, were not associated with hospitalization for medical misadventure, assault, or accidental poisoning. The likelihood of a rural resident being hospitalized for motor vehicle trauma is higher than for an urban resident. The likelihood that a rural resident is hospitalized for "other" non-work injury is higher than for an urban resident.ConclusionIn a relatively homogenous group of workers, and using a rigorous study design, we have demonstrated that the odds of other non-work injury are much higher for workers resident in and migrating to rural regions of Canada than they are for workers resident in or migrating to urban places.

The Criminal Justice System and Health Care

As the editors of The Criminal Justice System and Health Care point out (p. 4), the intersection between criminal law and medicine has been somewhat neglected in the academic literature (p. 33). The theme is an important one, and this volume covers some interesting ground. Three main areas are examined: the criminalisation of medical misadventure; medical behaviour which potentially shortens life; and disease transmission. The first four chapters on the criminalisation of medical misadventure link together well, giving the reader a well-rounded picture of the debate over the use of gross negligence manslaughter against individual health care professionals, and the question whether a subjective recklessness standard should be preferred (Brazier and Allen, Quick) and the possible alternatives to an individual-focused approach (Quick, Allen). The use of language deserves a preliminary mention. Quick notes that ‘language usage may be an important factor in shaping responses’ to medical misadventure (p. 33). For example, Merry uses ‘accidental’ rather than ‘negligent’ when describing cases of iatrogenic harm (p. 83). A distinction has been drawn in the literature between errors and violations, as described by Merry and McCall Smith: Errors are characteristically never deliberate. Violations … must be defined in the context of accepted rules, norms or principles, and constitute a deliberate deviation from them. They are not inevitably reprehensible, and indeed may be motivated by the best of intentions, yet they do involve choice – there is in a violation a clear volitional component. Violations are therefore always avoidable, although factors within the system or organisation may at times make it very difficult in practice to avoid them. Errors, by contrast, are unintentional and cannot be avoided simply through the exercise of choice.1

Medical Malpractice in Gastroenterology

Gastroenterologists commonly perceive themselves to be at increased legal risk because they perform invasive procedures. However, there is little published information about gastroenterology (GI) malpractice claims. The goal of this study was to evaluate available malpractice claim data within GI. This study was a database analysis of GI claims submitted by insurance companies to the Physician Insurers Association of America Data Sharing Project from January 1, 1985, to December 31, 2005. Another analysis from 2005 compared GI claims with other subspecialties. Sixty-six percent of physicians involved in claims had previous claims experience. The most common reasons for claims were errors in diagnosis (28%) and improper performance of a procedure (25%). Seventy-two percent of reported closed claims were settled out of court. Of 12,367 total claims in 2005, only 233 (1.8%) were within GI. GI ranked below other procedurally based subspecialties in numbers of claims per physician. GI does not rank highly among subspecialties in malpractice claims and only a minority of claims are procedure-related. Physicians with claims experience are likely to have further claims against them and should consider evaluating their practices.

Hémorragies alvéolaires

To explore the effect of various adverse hospital events on short- and long-term outcomes in a cohort of acutely ill hospitalized patients.In a secondary analysis of a retrospective cohort of acutely ill hospitalized patients with sepsis, shock, or pneumonia or undergoing high-risk surgery who were at risk for or had developed acute respiratory distress syndrome between 2001 and 2010, the effects of potentially preventable hospital exposures and adverse events (AEs) on in-hospital and intensive care unit (ICU) mortality, length of stay, and long-term survival were analyzed. Adverse effects chosen for inclusion were inadequate empiric antimicrobial coverage, hospital-acquired aspiration, medical or surgical misadventure, inappropriate blood product transfusion, and injurious tidal volume while on mechanical ventilation.In 828 patients analyzed, the distribution of 0, 1, 2, and 3 or more cumulative AEs was 521 (63%), 126 (15%), 135 (16%), and 46 (6%) patients, respectively. The adjusted odds ratios (95% CI) for in-hospital mortality in patients who had 1, 2, and 3 or more AEs were 0.9 (0.5-1.7), 0.9 (0.5-1.6), and 1.4 (0.6-3.3), respectively. One AE increased the length of stay, difference between means (95% CI), in the hospital by 8.7 (3.8-13.7) days and in the ICU by 2.4 (0.6-4.2) days.Potentially preventable hospital exposure to AEs is associated with prolonged ICU and hospital lengths of stay. Implementation of effective patient safety interventions is of utmost priority in acute care hospitals.

FREDERICK HOLMES. The Sickly Stuarts: The Medical Downfall of a Dynasty. Stroud, Sutton Publishing, 2003. xvi, 224 pp. 20.

This book aims to show “exactly how disease and disability brought down the Stuart dynasty” (12). It has its origins in the intellectual curiosity and fascination with the Stuart dynasty of a Distinguished Professor of Medicine at the University of Kansas Medical Center, Frederick Holmes. Professor Holmes turned his curiosity to good effect by undertaking formal academic study in history in the 1990s, culminating in a master’s degree in 1998. One offshoot of these labors was his realization that he could see and evaluate medical data in primary and secondary source material better than most historians. This, indeed, is the case, but his belief that it was poor health and medical misadventures that brought down the Stuart monarchy is much less securely based. While his detailed exploration of medical data, including that which can be culled from post-mortem examinations, renders accessible to the political historian much that would otherwise remain obscure or arcane, Professor Holmes puts an explanatory weight upon this evidence that it simply cannot bear. Few historians, for example, would be happy with the statement that “[t]he rise of parliamentary power in England during the seventeenth century was made possible by the progressive weakening of the House of Stuart by disease and disability” (3), or with the assertion that “[t]he power of the Stuarts and the English monarchy slowly faded throughout the long seventeenth century as the Stuarts were brought down by a series of medical problems and Parliament simultaneously increased in power to fill the void” (2).

The Quality Promise

“Quality is our image” is the ACR’s motto. Quality is the most important service we can provide for our patients. Our patients are often impressed with our diagnostic skills. However, they have also heard about medical misadventures through such reports as the Institute of Medicine’s [1] To Err Is Human. As a result, our patients are increasingly interested not merely in access to health care but in access to quality health care. Quality health care has become an expectation. In my frequent meetings with legislators, payers, and other groups interested in physicians’ performance, the quality topic immediately enters the conversation.

Failure to diagnose appendicitis among top medical misadventures

![Figure][1] Dr. Reynolds A 6-year-old girl presents to her pediatrician with six hours of abdominal pain and vomiting. She has had three loose stools. On examination, the patient does not seem tender, is not guarding and is not dehydrated. She drinks juice in the office and goes home.

The wake of a red sox fan

The wake of a red sox fan

Shakespeare's Chancre: Did the Bard Have Syphilis?

Shakespeare's obsessive interest in syphilis, his clinically exact knowledge of its manifestations, the final poems of the sonnets, and contemporary gossip all suggest that he was infected with "the infinite malady." The psychological impact of venereal disease may explain the misogyny and revulsion from sex so prominent in the writings of Shakespeare's tragic period. This article examines the possibility that Shakespeare received successful treatment for syphilis and advances the following new hypothesis: Shakespeare's late-life decrease in artistic production, tremor, social withdrawal, and alopecia were due to mercury poisoning from syphilis treatment. He may also have had anasarca due to mercury-related membranous nephropathy. This medical misadventure may have prematurely ended the career of the greatest writer in the English language.

A Brief Introduction to Medical Misadventure

This article examines the development of medical misadventure law in New Zealand. It discusses the various pieces of legislation impacting on the definition of "medical misadventure" as well as considering the punitive damages cases that are emerging outside ACC against allegedly negligent health professionals and organisations. The author states that the difficulty in devising an appropriate system of accountability lies in the special trust of the doctor patient relationship.

Medical Misadventure and Accident Compensation in New Zealand: An Incentives-Based Analysis

This article discusses the role of incentives in reducing the occurrence of medical misadventure. The author argues that appropriate incentives may induce the practice of insuring appropriate levels of precaution by sharing the costs of insufficient levels of precaution between those with the power to exert clinical precaution (practitioners) and monitor and enforce its exertion (administrative agencies), and the victims who otherwise bear the costs of inadequate levels of precaution being taken. The respective ability of tortbased and nofault systems to achieve this level of care is discussed, and then applied in the New Zealand ACC situation.The author concludes that from the available evidence, incentives associated with a faultbased system are extremely difficult, if not impossible, to replicate in a nofault system. This is even harder to achieve when public funding of both the ACC and health systems further reduces the incentives potentially available when individuals must meet the cost of their own treatment and liability insurance.

Ending Fault in Accident Compensation: Issues and Lessons from Medical Misadventure

This paper suggests that emphasising prevention and rehabilitation are the key directions that the ACC system should move in the future. Compensation should be phased out in favour of rehabilitation as the primary means of remediation. Additionally the author recommends removing inequity in the system by phasing out accidents as the basis for entitlement and replacing it with an entitlement regime based on injury outcomes. This discussion is located within the context of the treatment of medical misadventure under the ACC system.

From Bolam to Ipp: an examination of the standard of care in medical negligence cases since 1957

The past 50 years have seen significant changes in the definition of the standard of care in claims for medical negligence, beginning with Bolam in 19571 and ending with the implementation of the Ipp proposals in 2002−2003.2 Over this time there has been much debate and, on some occasions, hysterical outbursts by both doctors and plaintiff lawyers. On the one hand, doctors claimed that it was nonsensical for the courts to determine the standard of care, as they had no training, experience or knowledge of medicine and surgery. Lawyers, on the other hand, claimed that plaintiff rights were being eroded or removed by common law and legislative changes. A reasoned non-partisan view of the developments to date leads to the conclusion that the legal position now in place is sensible and rational as it takes into account the needs of both the medical profession and the community at large. Persons injured negligently by medical hands must be compensated, adverse events secondary to medical misadventure should be accepted and persons undergoing medical or surgical treatment have a responsibility (as do doctors) to satisfy themselves that they are aware of all that they might wish to know about a treatment or procedure. Finally, the community at large must accept that medical indemnity insurance premiums must be affordable for, if they are not, doctors will leave the profession or be forced to raise fees to levels that, in themselves, will be unaffordable. Following the Bolam decision, it was accepted that the standard of care was that held ‘by a responsible body of medical men skilled in that particular art’1 and, furthermore, that ‘a man is not negligent if he is acting in accordance with such a practice, merely because there is a body who would take a contrary view’. Thus the standard that prevailed for many years was, for practical purposes, that if a number of your colleagues practised in the same way, and there may be other methods, that standard was acceptable. Standards need not be too high nor too low but were to be ‘fair and reasonable’.1, 3 The concept of reasonableness is one that is repeated over the years but, at least in earlier times, seems to be related more to the medical profession's notion of reasonableness rather than a wider community view that came to be adopted in later cases, such as Reibl v Hughes,4Rogers v Whitaker,5Chapel v Hart6 and in the Ipp Report.2 It has now become accepted that the patient/plaintiff has a right to know about a much wider range of information than had previously been considered necessary by the medical profession. Thus medical paternalism has gradually disappeared and doctors have had to ensure that all aspects of treatment were discussed, including those that the patient would find material in making an informed consent. Finally, in Rogers v Whitaker, an Australian court made quite clear the importance of informing patients of risks that were material, special or unusual. From the doctor's point of view this was seen as the pendulum swinging in favour of the plaintiff and the court. Subsequently, the notion that the common practice principle did not extend to customs or practices that ignore the elementary dictates of caution were accepted. The latter was extensively examined in Bolitho,7 where the court took the view that for expert testimony to be acceptable it must come not only from a source that was responsible, reasonable and respectable, but also that it would withstand the test of logical analysis, that is, it was reasonable. This notion was taken up in the Ipp Report where the Committee set the standard of care as not only being held ‘by a significant number of respected practitioners in the field’2 but also that this opinion not be ‘irrational’, subsequently modified in some states (e.g. Victoria) to ‘unreasonable’.8 Ipp has also made much clearer the number of doctors required to hold the standard view while accepting that there may be more than one. These and other recommendations made in Bolitho and Ipp move the standard back towards a more balanced approach where the rights of both patients and their doctors are considered in a more reasoned, fairer and rational light. The question now is, of course, will the courts be more accepting of the medical view of the prevailing standard of care? The answer is awaited with considerable interest.

The Sickly Stuarts—the Medical Downfall of a Dynasty

The Sickly Stuarts—the Medical Downfall of a Dynasty