Professional liability in orthopaedics and traumatology in Italy

Reasons for malpractice claims after primary total hip arthroplasty in France: Insurance data from 240 claims from 2014 to 2017

INTRODUCTION

Total hip arthroplasty (THA) is one of the most frequent orthopedic surgery procedures, and orthopedic surgeons are among the most frequently accused of malpractice by their patients. Identifying the main reasons for malpractice claims after THA is a prior condition to reducing their frequency. The quality of the preoperative risk information given to the patient by the surgeon is crucial for these purposes. Data specific to THA are sparse in France, and we therefore conducted a retrospective study (1) to determine whether the outcome of medico-legal expert appraisal correlated with the quality and traceability of preoperative information, and (2) to identify the most frequent grounds for complaint after primary THA.

HYPOTHESIS

The quality of patient information partly determines expert appraisal.

MATERIAL AND METHOD

A retrospective study was conducted based on data from the Branchet medical professional insurance agency for malpractice claims following THA over the period 2014-2017, with 240 complete files, for 125 women and 115 men. Data comprised: type of procedure, main grounds of complaint (complications), positive or negative expert appraisal, quality of preoperative patient information, amounts of compensation accorded and fees paid, and the practitioner's liability. We assessed correlations between information quality and liability.

RESULTS

Surgical site infection and neurologic deficit were the two main grounds for malpractice claims. In the 240 files, cases for 106 operations (44.2%) were submitted to arbitration, 95 (39.6%) were brought to court, and 39 (16.2%) were settled out of court. The practitioner was held at least partly liable in 40 files (16.7%). Information to the patient was deemed imperfect or poor for 119 files (49.6%) and good in 121 (50.4%). Mean compensation was €30,940 (range, €0 to €198,100). In 27 of the 40 cases of liability (67.5%), the information to the patient was deemed imperfect or poor. Twenty-six of the 40 cases (65%) were settled out of court. In case of poor information, there was a significant risk for the practitioner to be held liable: 7.5 vs. 25% (p=0.003).

DISCUSSION

The present study listed the main complications underlying malpractice claims after THA: infection, neurologic complications, and limb-length discrepancy. This should enable practitioners to improve patient information so as to reduce the rate of malpractice claims or at least decrease the practitioner's liability, as the study found a correlation between information quality and expert appraisal.

LEVEL OF EVIDENCE

IV; retrospective study.

Medical errors, affected sites, and adverse consequences among patients in the orthopaedic department: Does age matter?

Background

Orthopaedics have become the focus of research on patient safety due to the high incidence of medical errors. Previous studies were based on all orthopaedic patients and rarely conducted empirical analyses from the perspective of age. This study aimed to fill the academic gap in the age variable by comparing medical errors, affected sites, and adverse consequences in orthopaedic patients.

Methods

This retrospective study included 329 litigation claims against orthopaedists using data from China Judgments Online. First, we performed computer crawling and screened 5,237 litigation documents using keywords, including medical errors. Second, 2,536 samples were retained through systematic random sampling, and 549 irrelevant cases were deleted after manual reading. Finally, three clinicians from different medical departments selected 329 incidents related to orthopaedics for further analysis, according to the description of the lawsuits. Three other professional orthopaedists evaluated the patients' ages, affected sites of medical errors, and adverse consequences.

Results

The greatest number of medical errors was observed in the joints (30.43%) for all orthopaedic patients. However, adult patients (aged 18-60 years) were most susceptible to errors in the extremities (30.42%). A higher rate of complications was associated with a higher rate of morbidity/mortality for the corresponding patients. Medical errors correlated with complications occurred in the following sites: joints (15.38%), extremities (12.50%), spine (16.95%), multiple sites (15.38%), and hands and feet (14.81%). In addition to surgical errors, over 10% of all orthopaedic patients experienced missed diagnoses. The incidence of insufficient adherence to informed consent obligations was 13.5% among adult patients and was much higher in paediatric and older adults patients. When orthopaedic patients suffered from medical technical errors, iatrogenic mortality/morbidity would decrease by 0.3% for one unit increase in age.

Conclusion

Dividing patients into different ages demonstrated diverse results in terms of medical errors and affected sites. Negligence in diagnosis and examination can be fatal factors that endanger safety, and complications may cause morbidity/mortality. When patients suffered from technical errors, age is inversely proportional to mortality/morbidity. Special attention needs to be paid to technical errors in the younger older adults population (60-64 years old), which has inspired implications in promoting aging and public health.

Medical Malpractice Among Orthopedic Surgeons in Greece: An Analysis of Court Decisions

Introduction Medical malpractice occurs when a physician, through incorrect medical action or omission, causes the patient to suffer physical harm or loss of life. Orthopedics is a high-risk medical specialty. Orthopedic surgery encompasses a wide range of procedures, including joint replacements, fracture repairs, and spinal surgeries. While orthopedic surgeons strive to provide optimal care to their patients, medical liability claims are a reality they must face. The aim of this study is to analyze the epidemiological data of judicial decisions and cases in Greece for the Specialty of Orthopedics. Material and methods Published court decisions involving medical liabilities of orthopedic surgeons and anesthesiologists, or only orthopedic surgeons were searched, in the period between 1985 and 2021. The judicial decisions were analyzed by an experienced anesthesiologist and an orthopedic surgeon based on medical knowledge and experience. Patients' age, gender, date of operation and the causes that led to the doctors' persecution were also recorded. Results Seventy court decisions of the first, second, and third degree were found. These decisions related to 34 cases: seven convictions for manslaughter, 18 convictions for bodily harm, and nine acquittals - exempting compensation. They involved 11 men and 13 women. The claims mainly related to intraoperative and postoperative complications in 20 (83.3%) of the 24 cases. Complications in elective spinal and lower extremity surgeries represent 50% (n = 12) of cases, while postoperative complications account for 16.7% of cases (n = 4). Conclusions The present study concluded that an accumulation of experience in large orthopedic centers is needed to improve the performance of orthopedic surgeons during surgery and patient monitoring. Many legal cases are due to the mismatch between patient expectations and the limitations in medicine. Thorough preoperative control and better preoperative communication with the patient are needed, in order to improve the performance of orthopedic surgeons and prevent a significant part of the claims.

A Fifteen-Year Survey for Orthopedic Malpractice Claims in the Criminal Court of Rome

The number of legal disputes in the field of medical liability has increased exponentially in the last decades. The aim of this study is to investigate the outcomes of criminal cases against healthcare professionals in Italian criminal courts. The hypothesis is that the majority of cases are dismissed and/or most professionals in these cases are acquitted. This retrospective analysis considers criminal proceedings related to medical professional liability registered with the general register of crime reports of the Public Prosecutor’s Office of Rome in the time interval between 1 January 2000 and 31 December 2015. A total of 4793 criminal proceedings were ultimately identified. Proceedings related to the field of orthopedic trauma were then examined and identified. A complete analysis of 132 of the identified files (76.7%) was carried out. The field with the highest risk of disputes was determined to be the field of trauma. The most frequent complaint was found to arise from unsatisfactory surgical outcomes following elective surgery. The most affected anatomical district is the lower limb in both elective and trauma cases, followed by the upper limb in traumatology and spine cases. The surgeon is the most frequently quoted role of the professional involved. The number of physicians actually convicted (3.93%) and for whom liability was thus recognized, i.e., the existence of a causal link between their conduct and the event that took place was established, appears to be extremely small when compared with the far more significant values related to dismissals (53%) and acquittals (14.2%). Adequate legal reform aiming to reduce this disproportion is necessary to ensure physicians experience a more relaxed daily profession and to restore the original connotations of the doctor–patient relationship with the abolition of defensive medicine.

Litigations in orthopedics and trauma surgery: reasons, dynamics, and profiles

BACKGROUND

In recent literature, the increasing number of medical litigations, both in terms of the number of cases being filed and the substantive costs associated with lawsuits, has been described. This study aims to provide an overview of the profile of litigation for orthopedic and trauma surgery to describe the differences and the development of the number of cases over time.

PATIENTS AND MATERIALS

A retrospective review of all litigations between 2000 and 2017 was conducted using the institutional legal database. The causes of litigation were documented and classified into seven major categories. In addition to plaintiff characteristics, the litigation outcomes and the differences between emergency and elective surgery were analyzed.

RESULTS

A total of 230 cases were evaluated. The mean age of the plaintiffs was 44.6 ± 20.1 years, and 56.8% were female. The main reasons for litigation were claimed inappropriate management (46.1%), misdiagnosis (22.6), and poor nursing care (8.3%). Significantly more litigations were filed against surgeons of the orthopedic subspecialty compared with trauma surgeons (78%; p ≤ 0.0001). There were significantly fewer litigations per 1000 cases filed overall in 2009-2017 (65% less; p = 0.003) than in 2000-2008.

CONCLUSION

Our results could not confirm the often-stated trend of having more litigations against orthopedic and trauma surgeons. Although the absolute numbers increased, the number of litigations per 1000 patients treated declined. Patients who underwent elective surgery were more likely to file complaints than emergency patients.

Analysis of medical malpractice litigation following vertebral augmentation therapy in China from 2008 to 2018

The first case of vertebral augmentation therapy in mainland China was reported in 2000. Since then, it has been widely used in China as a minimally invasive procedure to treat vertebral compression fractures. However, the characteristics of malpractice litigation involving vertebral augmentation therapy remains unclear. This study aims to analyze the characteristics of medical malpractice litigation involving vertebral augmentation therapy in mainland China for the past 10 years. Two online legal databases were queried for court verdicts involving vertebral augmentation therapy from Jan 2009 to Dec 2018 in mainland China. Each case file was then thoroughly reviewed and data pertaining to defendants, plaintiffs, case outcomes, allegations, and verdicts were abstracted, and descriptive analyses were performed. Level of evidence: LEVEL III. A total of 96 cases were enrolled for final analysis. The number of claims increased by five times during the past 10 years. More than two thirds (67.7%, n = 65) of the cases underwent percutaneous vertebroplasty, and 22.9% (n = 22) underwent percutaneous kyphoplasty, the rest (9.4%, n = 9) remained undefined. Paralysis was alleged in 35.4% of cases (n = 34), followed by significant physical injury (34.4%, n = 33). Cement leakage to spinal canal (44.8%, n = 43) is the most commonly cited reason for litigation, followed by incomplete informed consent (42.7%, n = 41), accidental dural puncture (20.8%, n = 20), unsatisfactory clinical outcome (18.8%, n = 18), and misdiagnosis (12.5%, n = 12). Acute pulmonary cement embolism (4.2%, n = 4), wrong-level vertebrae procedure (3.1%, n = 3) and postoperative infection (2.1%, n = 2) were less common causes for concern. Doctors successfully defended themselves only in 8 (8.3%) cases, which resulted in no indemnity payment. The rest 88 (91.7%) cases were closed with a mean verdict payout of 361,580 Yuan (51,654 US dollars). There is a quickly rising trend in the number of medical malpractice litigation involving vertebral augmentation therapy in China. Identifying the most common reasons for litigation and summarizing their characteristics may help decrease litigation rate and improve the patient experience.

Learning from informed consent litigation to improve practices: A systematic review

OBJECTIVE

To describe the reasons that lead judges to qualify malpractice as a lack of information, then rule in favour or not of the health professional (HP).

METHODS

We conducted a systematic review of case law relating to the breach of disclosure obligations over a ten-year period from 2010 to 2020. We used 3 legal databases: Légifrance, Dalloz and Lexis 360, all identified as the most exhaustive.

RESULTS

Of the 514 law cases included: judges found malpractice owing to lack of information in 377 (73.3%) cases. Among the latter, malpractices were lack of risk information (N = 257, 68.2%), lack of proof of information (N = 243, 64.5%) and/or lack of information on therapeutic alternatives (N = 49, 13.0%). These malpractices resulted in a conviction of the HP in 268 (71.1%) of the cases.

CONCLUSION

Case law is an important source of information for improving the quality of HP, lawyers, and judges' practices.

PRACTICE IMPLICATIONS

This review suggests that.

Poor compliance documenting informed consent in trauma patients with distal radius fractures compared to elective total knee arthroplasty

Background

The purpose of this study was (1) to evaluate the adequacy of informed consent documentation in the trauma setting for distal radius fracture surgery compared with the elective setting for total knee arthroplasty (TKA) at a large public hospital and (2) to explore the relevant guidelines in New Zealand relating to consent documentation.

Methods

Consecutive adult patients (≥16 years) undergoing operations for distal radius fractures and elective TKA over a 12‐month period in a single‐centre were retrospectively identified. All medical records were reviewed for the risks and complications recorded. The consent form was analysed using the Flesch Reading Ease Score (FRES) and the Simple Measure of Gobbledygook (SMOG) index readability scores.

Results

A total of 133 patients undergoing 134 operations for 135 distal radius fractures and 239 patients undergoing 247 TKA were included. Specific risks of surgery were recorded significantly less frequently for distal radius fractures than TKA (43.3% versus 78.5%, P < 0.001). Significantly fewer risks were recorded in the trauma setting compared to the elective (2.35 ± 2.98 versus 4.95 ± 3.33, P < 0.001). The readability of the consent form was 40.5 using the FRES and 10.9 using the SMOG index, indicating a university undergraduate level of reading.

Conclusions

This study has shown poor compliance in documenting risks of surgery during the informed consent process in an acute trauma setting compared to elective arthroplasty. Institutions must prioritize improving documentation of informed consent for orthopaedic trauma patients to ensure a patient‐centred approach to healthcare.

Results From an All Wales Trainee Led Collaborative Prospective Audit on Management of Ankle Fractures

Aim The purpose of this all Wales national audit was to compare compliance against British Orthopedic Association Standards for Trauma (BOAST) guidelines on the management of ankle fractures. Methods A multi-center prospective audit of the management of adult ankle fractures was conducted between February 2, 2020, and February 17, 2020, via the Welsh Orthopedic Research Collaborative (WORC). Regional leads were recruited in nine NHS hospitals across six university health boards, and recruited collaborators in their respective hospitals. Questionnaires for the data collection on both surgical and conservative management were made available via a password-protected website (walesortho.co.uk). We defined early weight-bearing (EWB) as unrestricted weight-bearing on the affected leg within three weeks of injury or surgery and delayed weight-bearing (DWB) as unrestricted weight-bearing after three weeks of injury or surgery. Results A total of 28 collaborators contributed data for 238 ankle fractures. Poor documentation at the time of injury was noted. Less than 50% of patients with posterior malleolus fracture had a CT scan for further evaluation. Eighty-four percent of the non-operatively treated patients did not have a weight-bearing X-ray (WBXR). Patients who had a WBXR were more likely to be allowed EWB but this was not statistically significant. EWB was allowed in 59.43% and 10% of the non-operatively and operatively treated patients, respectively. DWB was higher in patients who had fixation of the posterior malleolus or syndesmosis. Conclusion There is poor compliance with BOAST guidelines on the management of ankle fractures across Wales. We need to improve documentation and also consider performing a CT scan when the posterior malleolus is fractured. A weight-bearing X-ray should be performed more often to ascertain the stability of an ankle fracture, and those that are deemed stable should be treated with early weight-bearing. The guidelines need to be clearer regarding weight-bearing after fixation especially when posterior malleolus and/or syndesmosis are fixed.

Postoperative pain and infection are the most frequent reasons for legal action after knee arthroscopy: a 5-year review based on two private insurance French companies after arthroscopy

PURPOSE

The objective of this study was to determine the reasons for complaints and describe the judicial means upstream of France's courts following arthroscopy.

METHODS

This is a retrospective observational study including all compensation records related to arthroscopic surgery, collected from the two leading French insurance organizations: MACSF and Branchet companies, from 2014 to 2018. Three medical experts performed the protocol and analysis.

RESULTS

Finally, 247 procedures were included. The most common motives were: the appearance or persistence of pain (43.7%), postoperative infection (29.1%), technical errors (10.5%), nerve damage (5.7%), arterial lesions (2.8%), side errors (2.4%). Knee arthroscopies were more at risk of legal action for infection (p = 0.0006), and for disappointing results or persistent pain (p = 0.001). The first recourse was the conciliation and compensation commission (CCI) in 136 cases (55.1%), the civil court (TGI) in 88 cases (35.6%) and amicable settlement in 23 cases (9.3%). The mean time between surgery and the complaint was 32.8 ± 25.7 months, and was shorter in the case of an amicable procedure (p < 0.001). The lawsuit's mean duration was 15.6 ± 11.2 months, but longer in case of civil proceedings (p < 0.0001). The experts found no negligence in 81.8% of cases (n = 202). Infections were the leading cause of recourse to the conciliation and compensation commission (p < 0.0001), while technical errors were the main reason for complaints settled in an amicable procedure (p = 0.035). It was found more proven negligence in case of amicable procedures (p < 0.0001). The mean amount of compensation was 60,968.45€. No significant difference could be found regarding the median values of compensation between the reason of complaint. The amount of compensation was higher in civil court proceedings than in any others (p = 0.02).

CONCLUSION

The main reasons for arthroscopy litigation in France are reported in this study, specifying how they are managed upstream of possible legal proceedings. The knee is the main joint involved. Patient information, close follow-up associated with early and appropriate management of complications are the main ways to reduce complaints.

LEVEL OF EVIDENCE

IV.

Informed Consent for the Orthopaedic Surgeon

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In the United States, orthopaedic surgeons have a legal obligation to obtain informed consent from patients before performing surgery; it is a process that includes a signed written document.

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There are specific legal requirements that vary somewhat by state but generally include disclosure and documentation of the diagnosis, an explanation of the recommended procedure, a conversation about the risks and benefits of the procedure, and a discussion about alternative treatments.

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Inadequate disclosure of risks and alternatives is associated with increased indemnity risk.

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Studies have shown that many consent processes and forms are suboptimal.

Medical Liability: Review of a Whole Year of Judgments of the Civil Court of Rome

Background: Complaints about medical malpractice have increased over time in Italy, as well as other countries around the world. This scenario, perceived by some as a “malpractice crisis”, is a subject of debate in health law and medical law. The costs arising from medical liability lawsuits weigh not only on individual professionals but also on the budgets of healthcare facilities, many of which in Italy are supported by public funds. A full understanding of the phenomenon of medical malpractice appears necessary in order to manage this spreading issue and possibly to reduce the health liability costs. Methods: The retrospective review concerned all the judgments drawn up by the Judges of the Civil Court of Rome, XIII Chamber (competent and specialized section for professional liability trials) published between January 2018 and February 2019. Results: The analysis of data concerning the involved parties showed that in 84.6% of the judgments taken into account, one or more health facilities were sued, while in 58.2% of cases, one or more health workers were present among the defendants. When healthcare providers are the only ones to be summoned, it is dentists and aesthetic doctors/plastic surgeons who undergo most of the claims. In the overall period analyzed, the amount paid was 23,489,254.08 EUR with an average of 163,119.82 EUR. Conclusion: The evidence provided by the reported data is a useful tool to understand medical malpractice in Italy, especially with regard to the occurrence of the phenomenon at a legal level, an aspect still hardly mentioned by existing literature.

A Five-Year Survey for Plastic Surgery Malpractice Claims in Rome, Italy

(1) Introduction: Medical malpractice claims against both health institutions and physicians are a crucial topic in Italy, as well as in other countries, particularly regarding civil proceedings. Our study reports an analysis of all of the malpractice judgments concerning plastic surgery decided in the Civil Court of Rome between 2012 and 2016. (2) Methods: the database of the Observatory Project on Medical Responsibility (ORMe) was analyzed, which collects all of the judgments of the Civil Court of Rome, that is, the first instance district court. Therefore, neither the jurisprudence of the second level court nor that of the Supreme Court was taken into account. (3) Results: 144 judgments concerning plastic surgery were delivered in the five-year period of 2012–2016 (corresponding to 10.6% of total professional liability verdicts of the Civil Court of Rome in the same period). In 101/144 cases (70.14%), the claim was accepted. A total of €4,727,579.00 was paid in compensation for plastic surgery malpractice claims, with a range from a minimum amount of €1555.96 to a maximum amount of €1,425,155.00 and an average compensation of €46,807.71 per claim that was significantly lower compared to other surgical disciplines. (4) Conclusions: Our data confirm that the analyzed branch has a high litigation rate, with a prevalence of convictions for cosmetic procedures over reconstructive ones, both for malpractice and for violation of the informed consent. Plastic surgery is also confirmed among those branches in which the professionals are more frequently sued compared to health institutions.

Litigation in arthroscopic surgery: a 20-year analysis of legal actions in France

PURPOSE

The main objective of this study was to identify the epidemiological characteristics of litigation following arthroscopic procedures, performed in private practice and public hospitals in France. The secondary objective was to establish a risk profile for medical malpractice lawsuits after arthroscopic surgery.

METHODS

All court decisions related to arthroscopic surgery between 1994 and 2020 were collected and reviewed cases from the two main French legal databases (Legifrance and Doctrine). Data were retrospectively collected and included: gender, joint and defendant's specialty involved, reason behind the lawsuit, initial indication and the type of arthroscopic procedure performed. The final verdicts as well as the indemnity awarded to the plaintiff (if any) were recorded.

RESULTS

One-hundred eighty cases met the inclusion criteria of the study and were analyzed: 58 cases were before administrative courts and 122 were before civil courts. An orthopaedic surgeon was involved alone or in solidum in 45.6% of cases (82/180), followed by anesthesiologists in 5.6% (10/180). The private surgery center or public hospital were implicated in 63.9% (115/180) of cases. The 2 most common joints involved in litigation following arthroscopic surgery were the knee (82.2%, n = 148) and the shoulder (11.1%, n = 20). The main reasons behind the lawsuit were related to postoperative infection in 78/180 cases and to a musculoskeletal complication in 45/180 cases (25%). A failure to inform was also reported in 34/180 cases (18.9%). Of the 180 cases, 122 cases (67.8%) resulted in a verdict for the plaintiff. The average indemnity award for the plaintiff was 77.984 euros [2.282-1.117.667]. A verdict for the plaintiff was significantly associated with postoperative infection or a wrong-side surgery, while technical error and musculoskeletal complications were more significantly likely to result in a verdict in favor of the defendant (p = 0.003).

CONCLUSION

This study evaluated and mapped lawsuits following after arthroscopic surgery in France over a period of more than 20 years. The main joint involved in lawsuits was knee. The main causes of lawsuits following arthroscopic surgery were related to postoperative infection, musculoskeletal complications and failure to inform.

LEVEL OF EVIDENCE

Level IV.

Socioeconomic Factors Influencing Self-reported Outcomes After Posterior Wall Fractures of the Acetabulum: Lessons Learned From a Hispanic Population

Introduction:

Demographic and socioeconomic factors are important determinants that may affect patient self-reported outcomes after acetabular fracture surgery. Hispanics, as a minority group, have an increased tendency to suffer demographic and socioeconomic disparities. At the present time, there is scant information regarding their role among Hispanic patients with acetabular fractures. The aim of this study was to investigate whether demographic or socioeconomic factors would affect satisfaction and self-reported functional outcomes in Hispanic patients who endured open reduction and internal fixation (ORIF) of posterior wall fractures of the acetabulum.

Methods:

A cross-sectional study of 78 patients with posterior wall fracture of the acetabulum treated with ORIF from 2011 to 2017 was performed. Data from demographics (age, sex, and body mass index [BMI]) and socioeconomic factors (household income, highest educational level achieved, employment status, type of medical insurance, workers' compensation involvement, and injury-related litigation process) were obtained and compared with the Short Musculoskeletal Form Assessment-46 (SMFA-46) questionnaire using a multivariable logistic regression analysis.

Results:

Unemployment was the most significant variable associated with dissatisfaction among 15 of the 46 responses of the SMFA-46 (P < 0.048). Patients who had an overweight or obese BMI and had an age of 41 years or older exhibited significantly worse outcomes in 7 of the 46 questions (P < 0.049). Finally, women were less likely to be satisfied in 1 of the 46 questions (P = 0.028). No notable difference was observed in any of the SMFA-46 responses regarding insurance plan, educational level, workers' compensation involvement, and injury-related litigation process.

Discussion:

A strong association exists between dissatisfaction after ORIF of posterior wall fractures of the acetabulum and employment status, BMI, and age among the Hispanic population. Addressing socioeconomic factors can be critical to overcome dissatisfaction and improve functional status among Hispanic patients with acetabular fractures.

Management of the essential data element in the differential diagnosis of oral medicine: An effective step in promoting oral health

BACKGROUND

Oral soft tissue diseases include a broad spectrum, and the wide array of patient data elements need to be processed in their diagnosis. One of the biggest and most basic challenges is the analysis of this huge amount of complex patient data in an increasing number of complicated clinical decisions. This study seeks to identify the necessary steps for collecting and management of these data elements through establishing a consensus-based framework.

METHODS

This research was conducted as a descriptive, cross-sectional study from April 2016 to January 2017, which has been performed in several steps: literature review, developing the initial draft (v. 0), submitting the draft to experts, validating by an expert panel, applying expert opinions and creating version v.i, performing Delphi rounds, and creating the final framework.

RESULTS

The administrative data category with 17 and the historical data category with 23 data elements were utilized in recording data elements in the diagnosis of all of the different oral diseases. In the paraclinical indicator and clinical indicator categories, the necessary data elements were considered with respect to the 6 main axes of oral soft tissue diseases, according to Burket's Oral Medicine: ulcerative, vesicular, and bullous lesions; red and white lesions of the oral mucosa; pigmented lesions of the oral mucosa; benign lesions of the oral cavity and the jaws; oral and oropharyngeal cancer; and salivary gland diseases.

CONCLUSIONS

The study achieved a consensus-based framework for the essential data element in the differential diagnosis of oral medicine using a comprehensive search with rich keywords in databases and reference texts, providing an environment for discussion and exchange of ideas among experts and the careful use of the Delphi decision technique.

Claims in orthopedic foot/ankle surgery, how can they help to improve quality of care? A retrospective claim analysis

Background

Orthopedic foot/ankle surgery is a high risk specialty when it comes to malpractice claims. This study aims to evaluate the incidence, characteristics and outcome of claims in this area.

Methods

This was a retrospective, 10-year claim analysis, with data from an anonymous database. Baseline claim/claimant characteristics were collected from all orthopedic foot/ankle-related cases.

Results

Of 460 claims in total, most were related to delay in/wrong diagnosis or to (complications of) elective surgical procedures. Whether a claim was settled was related to type of injury (fracture) and type of claim (diagnostic mistake). Median amount disbursed in settled claims was €12,549. Claim incidence did not increase over the years.

Conclusion

Missed fracture diagnosis and “failed”/disappointing results of elective surgical procedures were the most common causes for claims. Sufficient knowledge of missed (foot) fractures and clear communication/expectation management before elective procedures could help to improve quality of healthcare and patient satisfaction.

No-Fault Compensation From the Patient Compensation Association in Denmark After Primary Total Hip Replacement in Danish Hospitals 2005-2017

BACKGROUND

There is an annually rising number of performed total hip arthroplasty (THA) surgeries in Denmark and this is expected to become even more common. However, there are still risks of adverse events, which become the basis for compensation claims. In Denmark, there are no studies available concerning filed claims after THA. The aims of this study are to determine the incidence of claims related to THAs in Denmark, the reasons to claim, which claims lead to compensation, the amount of compensation, and trends over time.

METHODS

In this observational study, we analyzed all closed claims between 2005 and 2017 from the Danish Patient Compensation Association (DPCA). With the intention to contribute to prevention, we have identified the number and outcome of claims.

RESULTS

There were 2924 cases (ie, 2.5% of all THAs performed in this period). The approval rate was 54%. The number of claims filed was stagnant over time, except for a spike of metal-on-metal (MoM) prosthesis cases. The total payout was USD 29,591,045, and 87% of this was due to nerve damage (USD 9,106,118), infection (USD 6,046,948), MoM prosthesis (USD 4,624,353), insufficient or incorrect treatment (USD 472,500), and fracture (USD 2,088,110).

CONCLUSION

In total, 2.5% of all THAs performed between 2005 and 2017 lead to a claim submission at the DPCA. One of 2 claims were approved. The majority of payouts were due to nerve damage, infection, MoM prosthesis, insufficient or incorrect treatment, and fracture. Although DPCA manages claims for patients, the data can also provide beneficial feedback to arthroplasty surgeons with the aim of improving patient care.

Alleged malpractice in orthopaedics. Analysis of a series of medmal insurance claims

Background

Medical malpractice is an important topic worldwide, and orthopedics is a clinical branch that is considered to be at a high risk for claims. The analysis of a series of medmal insurance claims allows forensic pathologists, clinicians, and insurance companies to probe the risk of a specific clinical branch for medical malpractice claims and highlights areas where care may be improved. We investigated the main features of a major Italian insurance broker’s archive in order to identify recurrent pitfalls in this field.

Materials and methods

A retrospective study was carried out on orthopedics claims. The archive covered claims from 2002 to 2013 that targeted 1980 orthopedists.

Results

635 claims were found and analyzed with a focus on the clinical activity invocked in the claim, the presence of alleged team malpractice, the clinical outcome of the case, and the final forensic decision regarding the claim. 299 orthopedists had at least one malpractice claim made against them during the available period; 146 orthopedists were subject to more than one malpractice claim. Most of the claims regarded perioperative and operative cases, usually originating from civil litigation. The anatomical sites most commonly involved were the hip or knees, and sciatic nerve lesions were the main contributor.

Conclusions

Orthopedics is a medical specialty with a high risk for malpractice claims. In our study, medical malpractice was observed in nearly 50% of the cases—typically in surgery-linked cases resulting in permanent impairment of the patient. Death from orthopedics malpractice seemed to be rare.

Level of Evidence

IV.

Litigation in orthopedic surgery: What can we do to prevent it? Systematic analysis of 126 legal actions involving four university hospitals in France

INTRODUCTION

Orthopedic surgery produces 20% of medical malpractice claims. However only a few studies have examined the reasons for and consequences of these disputes, and they have usually been limited to a single hospital. This led us to perform a retrospective analysis of the claims at four teaching hospitals in northwestern France. The goals were (1) to describe the circumstances that led to these claims and recommend ways to prevent them, and (2) to describe the conduct of the proceedings and their financial and social outcomes.

HYPOTHESIS

A systematic analysis of litigation cases will provide accurate information on the circumstances leading to these claims.

METHODS

The study included 126 disputes settled between 2000 and 2010 and related to orthopedic or trauma care given at one of four teaching hospitals in northwestern France. The method of recourse, grounds of the complaint, type of surgical procedure, expert findings and amount of the award were systematically analyzed.

RESULTS

Of these 126 cases, 54 (43%) of them were submitted to the French CRCI (regional conciliation and compensation commission), 48 (39%) to the French administrative courts and 51 (41%) were settled amicably. Multiple methods of recourse were used in 21% of cases (n=27/126). The average length of administrative court proceedings was 36.7±27 months [4-102], which was significantly longer than the CRCI proceedings (22.7±17.9 months [3-80]) or out-of-court settlement (23.7±21.5 months [0-52]) (p<0.0001). Damages were sought for medical error or treatment-related risk in 67.5% of the complaints (n=85/126), and for failure to inform in 15.8% of cases (n=20/126). There was a suspected surgical site infection in 79.3% of cases (n=100/126). There were multiple grounds for complaint in 68.3% of cases (n=86/126). Poor communication between the physician and patient was identified in 26.2% of cases (n=33/126). Damages were awarded in 25% of cases (n=31/126), with an average award of €58,303±€91,601 [0-357,970].

CONCLUSION

The primary grounds for legal action are infection-related complications combined with a deterioration in the doctor-patient relationship. Disputes could be prevented by continuing efforts to combat hospital-acquired infections and providing better communications training.

LEVEL OF PROOF

IV (retrospective study).

Epidemiology of malpractice claims in the orthopedic and trauma surgery department of a French teaching hospital: A 10-year retrospective study

INTRODUCTION

Orthopedic and trauma surgery is the specialty for which claims for compensation are most often filed. Little data exists on the subject in France, especially in a teaching hospital. We conducted a retrospective study aimed at (1) identifying the epidemiological characteristics of patients filing claims against the orthopedic surgery and traumatology department of a teaching hospital in France, (2) analyzing the surgical procedures involved, the type of legal proceedings, and the financial consequences.

HYPOTHESIS

The epidemiological profile of proceedings seeking damages in France is consistent with the data from European and American studies.

MATERIALS AND METHODS

An observational, retrospective, single-center study of all claims for damages between 2007 and 2016 involving the orthopedic and trauma surgery department of a teaching hospital was carried out. Patients' epidemiological data, the surgical procedure, type of legal proceeding, and financial consequences were analyzed.

RESULTS

Of the 51,582 surgical procedures performed, 71 claims (0.0014%) were analyzed (i.e., 1/726 procedures). A significant increase in the number of cases (p=0.040) was found over a 10-year period. Of these, 36/71 (53.7%) were submitted to the French regional conciliation and compensation commission (CRCI), 23/71 (32.8%) were filed with the administrative court, and 12/71 (13.4%) were submitted for an amicable settlement. The most common reason for which patients filed claims was hospital-acquired infections, with 36/71 (50.7%) cases. Twenty-nine complaints (40.8%) resulted in monetary damages being awarded to the patient, with an average award of € 28,301 (€ 2,400-299,508). Damage awards were significantly higher (p<0.05) for cases involving surgery on a lower limb than those involving an upper limb.

CONCLUSION

Claims against orthopedic surgeons have been increasing significantly over the last 10 years. Although rare, they represent a significant cost to society. Hospital-acquired infections are the main reason for disputes in our specialization.

LEVEL OF EVIDENCE

IV, retrospective study.

Negligence claims following non-union and malunion of long bone fractures: An analysis of 15 years of data

INTRODUCTION

Non-unions and malunions are recognised to be complications of the treatment of long bone fractures. No previous work has looked at the implications of these complications from a medicolegal perspective.

METHODS

A complete database of litigation claims in Trauma and Orthopaedic Surgery was obtained from the NHS Litigation Authority. Two separate modalities of the treatment of long bone fractures were examined i) non-union and ii) acquired deformity. The type of complaint, whether defended or not, and costs were analysed.

RESULTS

There were claims of which 97 related to non-union and 32 related to postoperative limb deformity. The total cost was £8.2 million over a 15-year period in England and Wales. Femoral and tibial non-unions were more expensive particularly if they resulted in amputation. Rotational deformity cost nearly twice as much as angulation deformities.

CONCLUSIONS

The cosmetic appearances of rotational malalignment and amputation results in higher compensation; this reinforces an outward perception of outcome as being more important than harmful effects. Notwithstanding the limitations of this database, there are clinical lessons to be gained from these litigation claims.

[Clinical safety and professional liability claims in Orthopaedic Surgery and Traumatology]

The specialist in orthopaedic and traumatological surgery, like any other doctor, is subject to the current legal provisions while exercising their profession. Mandatory training in the medical-legal aspects of health care is essential. Claims against doctors are a reality, and orthopaedic and traumatological surgery holds first place in terms of frequency of claims according to the data from the General Council of Official Colleges of Doctors of Catalonia. Professionals must be aware of the fundamental aspects of medical professional liability, as well as specific aspects, such as defensive medicine and clinical safety. The understanding of these medical-legal aspects in the routine clinical practice can help to pave the way towards a satisfactory and safe professional career. The aim of this review is to contribute to this training, for the benefit of professionals and patients.

Litigation costs of wrong-site surgery and other non-technical errors in orthopaedic operating theatres

INTRODUCTION

This study reviews the litigation costs of avoidable errors in orthopaedic operating theatres (OOTs) in England and Wales from 1995 to 2010 using the National Health Service Litigation Authority Database.

MATERIALS AND METHODS

Litigation specifically against non-technical errors (NTEs) in OOTs and issues regarding obtaining adequate consent was identified and analysed for the year of incident, compensation fee, cost of legal defence, and likelihood of compensation.

RESULTS

There were 550 claims relating to consent and NTEs in OOTs. Negligence was related to consent (n=126), wrong-site surgery (104), injuries in the OOT (54), foreign body left in situ (54), diathermy and skin-preparation burns (54), operator error (40), incorrect equipment (25), medication errors (15) and tourniquet injuries (10). Mean cost per claim was £40,322. Cumulative cost for all cases was £20 million. Wrong-site surgery was error that elicited the most successful litigation (89% of cases). Litigation relating to implantation of an incorrect prosthesis (eg right-sided prosthesis in a left knee) cost £2.9 million. Prevalence of litigation against NTEs has declined since 2007.

CONCLUSIONS

Improved patient-safety strategies such as the World Health Organization Surgical Checklist may be responsible for the recent reduction in prevalence of litigation for NTEs. However, addition of a specific feature in orthopaedic surgery, an 'implant time-out' could translate into a cost benefit for National Health Service hospital trusts and improve patient safety.

[Analysis of judicial sentences issued against traumatologists between 1995 and 2011 as regards medical negligence]

INTRODUCTION AND OBJECTIVES

Traumatology and Orthopaedic Surgery is one of the specialities with most complaints due to its scope and complexity. The aim of this study is to determine the characteristics of the complaints made against medical specialists in Traumatology, taking into account those variables that might have an influence both on the presenting of the complaint as well as on the resolving of the process.

MATERIAL AND METHODS

An analysis was performed on 303 legal judgments (1995-2011) collected in the health legal judgements archive of the Madrid School of Medicine, which is linked to the Westlaw Aranzadi data base.

RESULTS

Civil jurisdiction was the most used. The specific processes with most complaints were bone-joint disorders followed by vascular-nerve problems and infections. The injury claimed against most was in the lower limb, particularly the knee. The most frequent general cause of complaint was surgical treatment error, followed by diagnostic error. There was lack of information in 14.9%. There was sentencing in 49.8% of the cases, with compensation mainly being less than 50,000 euros.

CONCLUSIONS

Traumatology and Orthopaedic Surgery is a speciality prone to complaints due to malpractice. The number of sentences against traumatologists is high, but compensations are usually less than 50,000 euros. The main reason for sentencing is surgical treatment error; thus being the basic surgical procedure and where precautions should be maximised. The judgements due to lack of information are high, with adequate doctor-patient communication being essential as well as the correct completion of the informed consent.

Development a minimum data set of the information management system for burns

BACKGROUND

Burns are the most common and destructive injuries in across of the world and especially in developing countries. Nevertheless, a standard tool for collecting the data of burn injury has not been developed yet. The purpose of this study was to develop a minimum data set (MDS) of the information management system for burns in Iran.

MATERIALS AND METHODS

This descriptive and cross-sectional study was performed in 2014. Data were collected from hospitals affiliated with Hormozgan and Iran University of Medical Sciences and medical documents centers, emergency centers and legal medicine centers located in Bandar Abbas city, in addition to internet access and library. Investigated documents were burn injury records in 2013, and documents that retrieved from the internet, and printed materials. Records were selected randomly based on T20-T29 categories from ICD-10. Data were collected using a checklist. In order to make a consensus about the data elements the decision Delphi technique was applied using a questionnaire. The content validity and reliability of questionnaire were assessed by expert's opinions and test-retest method, respectively.

RESULTS

An MDS of burns was developed. This MDS divided into two categories: administrative and clinical with six and 17 section and 161 and 311 data elements respectively.

CONCLUSIONS

This study showed that comprehensive and uniform data elements about burns do not exist in Iran. Therefore a MDS was developed for burns in Iran. Development of an MDS will result in standardization and effective management of the data through providing uniform and comprehensive data elements for burns. Thus, comparability of the extracted information from different analyses and researches will be possible in various levels. In addition, establishment of policies and prevention and control of burns will be possible, which results in the improvement of the quality of care and containment of costs.