Why Do Vascular Surgeons Get Sued? Analysis of Claims and Outcomes in Malpractice Litigation

Editor's Choice - Development and Testing of Step, Error, and Event Frameworks to Evaluate Technical Performance in Peripheral Endovascular Interventions

OBJECTIVE

Tools for endovascular performance assessment are necessary in competency based education. This study aimed to develop and test a detailed analysis tool to assess steps, errors, and events in peripheral endovascular interventions (PVI).

METHODS

A modified Delphi consensus was used to identify steps, errors, and events in iliac-femoral-popliteal endovascular interventions. International experts in vascular surgery, interventional radiology, cardiology, and angiology were identified, based on their scientific track record. In an initial open ended survey round, experts volunteered a comprehensive list of steps, errors, and events. The items were then rated on a five point Likert scale until consensus was reached with a pre-defined threshold (Cronbach's alpha > 0.7) and > 70% expert agreement. An experienced endovascular surgeon applied the finalised frameworks on 10 previously videorecorded elective PVI cases.

RESULTS

The expert consensus panel was formed by 28 of 98 invited proceduralists, consisting of three angiologists, seven interventional radiologists, five cardiologists, and 13 vascular surgeons, with 29% from North America and 71% from Europe. The Delphi process was completed after three rounds (Cronbach's alpha; αsteps = 0.79; αerrors = 0.90; αevents = 0.90), with 15, 26, and 18 items included in the final step (73 - 100% agreement), error (73 - 100% agreement), and event (73 - 100% agreement) frameworks, respectively. The median rating time per case was 4.3 hours (interquartile range [IQR] 3.2, 5 hours). A median of 55 steps (IQR 40, 67), 27 errors (IQR 21, 49), and two events (IQR 1, 6) were identified per case.

CONCLUSION

An evaluation tool for the procedural steps, errors, and events in iliac-femoral-popliteal endovascular procedures was developed through a modified Delphi consensus and applied to recorded intra-operative data to identify hazardous steps, common errors, and events. Procedural mastery may be promoted by using the frameworks to provide endovascular proceduralists with detailed technical performance feedback.

An Analysis of Malpractice Litigation of Vascular Surgeons in Cases Involving Aortic Pathologies

OBJECTIVE

The aim of this study was to analyze malpractice claims for aortic pathologies and to assess if there has been a change in rate of malpractice lawsuits with evolution of endovascular therapy.

METHODS

Malpractice lawsuits were individually screened and compiled from the Westlaw database from 2000 to 2017 through use of relevant search terms. Data were collected of allegations, diagnoses, and outcomes of each case and compared.

RESULTS

268 unique cases were included in this study, with aneurysms (54%, n = 145) and dissection (35%, n = 94) making up the majority. There was a defendant verdict in 53% (n = 141), plaintiff verdict in 24% (n = 65), and settlements in 23% (n = 62) of lawsuits. Litigation was higher in the Midwest and Northeast. There was a gradual decline in litigation overall, however endovascular case numbers remained constant. There was negligible difference in the primary allegation underlying the litigation for various aortic pathologies, time to litigation and award between open and endovascular procedures.

CONCLUSION

The proportion of litigation for clinical negligence in endovascular cases amongst all vascular surgical lawsuits is increasing. As novel methods of endovascular therapy emerge, it is imperative that physicians remain vigilant to legal considerations to minimize malpractice risk.

Medical Malpractice Trends in Foot and Ankle Surgery

Medical malpractice lawsuits can place significant economic and psychologic burden on a provider. Orthopedic surgery is one of the most common subspecialties involved in malpractice claims. There is currently no study examining malpractice lawsuits within foot and ankle surgery. Accordingly, the purpose of this work is to examine trends in malpractice claims in foot and ankle surgery. The Westlaw legal database was queried for lawsuits pertaining to foot and ankle surgery from 2008 to 2018. Only cases involving medical malpractice were included for analysis. All available details pertaining to the cases were collected. This included plaintiff demographic and geographic data. Details regarding the cases were also collected such as anatomical location, pathology, complications, and case outcomes. Forty-nine malpractice lawsuits pertaining to foot and ankle were identified. Most plaintiffs in these cases were adult females, and the majority of cases occurred in the northeast (53.1%). The most common anatomical region involved in claims involved the forefoot (29%). The majority of these claims involved surgery (65%). Infection was the most common complication seen in claims (22%). The jury ruled in favor of the defendant surgeon in most cases (73%). This is the first study to examine trends in medical malpractice within foot and ankle surgery. Infection was the most frequent complication seen in claims and forefoot surgery was the most common anatomic location. A large portion of claims resulted after nonoperative treatment. A better understanding of the trends within malpractice claims is crucial to developing strategies for prevention.

Current Trends and Predictors of Case Outcomes for Malpractice in Colonoscopy in the United States

BACKGROUND

Over 14 million colonoscopies are performed annually, and this procedure remains the largest contributor to malpractice claims against gastroenterologists. The aim of this study was to evaluate reasons for litigation and predictors of case outcomes.

MATERIALS AND METHODS

Cases related to colonoscopy were reviewed within the Westlaw legal database. Patient demographics, reasons for litigation, case payouts, and verdicts were assessed. Multivariate regression was used to determine predictors of defendant verdicts.

RESULTS

A total of 305 cases were included from years 1980 to 2017. Average patient age was 54.9 years (range, 4 to 93) and 52.8% of patients were female. Juries returned defendant and plaintiff verdicts in 51.8% and 25.2% of cases, respectively, and median payout was $995,000. Top reasons for litigation included delay in treatment (65.9%) and diagnosis (65.6%), procedural error (44.3%), and failure to refer (25.6%). Gastroenterologists were defendants in 71% of cases, followed by primary care (32.2%) and surgeons (14.8%). Cases citing informed consent predicted defendant verdict (odds ratio, 4.05; 95% confidence interval, 1.90-9.45) while medication error predicted plaintiff verdict (odds ratio, 0.18; 95% confidence interval, 0.04-0.59). Delay in diagnosis (P=0.060) and failure to refer (P=0.074) trended toward plaintiff verdict but did not reach significance. Most represented states were New York (21.0%), California (13.4%), Pennsylvania (13.1%), Massachusetts (12.5%).

CONCLUSIONS

Malpractice related to colonoscopy remains a significant and has geographic variability. Errors related to sedation predicted plaintiff verdict and may represent a target to reduce litigation. Primary care physicians and surgeons were frequently cited codefendants, underscoring the significance of interdisciplinary care for colonoscopy.

Vascular Surgeons as Expert Witnesses in Malpractice Litigation

BACKGROUND

This study investigates the role of vascular surgeons as expert witnesses in United States' malpractice claims.

MATERIALS AND METHODS

We reviewed the Westlaw database from 1999 through 2014 using the search terms "vascular" and "surgeon". Case defendant, plaintiff, allegation, and verdict were compiled. Surgeon expert witness demographic data including age, practice duration, scholarly impact (H-index) and practice setting were reviewed using faculty websites, state licensing boards, and Scopus database.

RESULTS

A total of 785 cases were identified, Three-hundred seventy-seven with a vascular surgeon as the plaintiff or defense expert witness. Vascular surgeons were defense experts in One-hundred thirty one (34.75%) cases, plaintiff experts in One-hundred eighteen (31.3%), both plaintiff and defense experts in Ninty six (25.46%), or unspecified in Thiry two cases (8.29%). Two-hunder eighty three individual expert witnesses were identified. Vascular surgeon experts who testified 4 or more times were likely to be plaintiff experts (32.5% versus 18.7%, P <0.05). Mean years of practice (23.5 versus 24.2, P = 0.10) between plaintiff and defense experts was comparable. Plaintiff experts were more likely in non-academic practice (64.4% versus 52.5%, P <0.05) with lower scholarly impact (H-index 12.8 versus 16.7, P <0.05).

CONCLUSIONS

A small percentage of vascular surgeons were experts in multiple cases, especially as plaintiff witnesses. Vascular surgeons as plaintiff's witnesses have similar years of age, work less in an academics, and have lower scholarly impact than defense witnesses. While national organizations provide guidelines defining expert witness qualifications, the required credentials vary by State. Development of minimum qualifications nationally may improve consistency in expert credentialing and lead to more ethical trial representation.

Malpractice trends in shoulder and elbow surgery

BACKGROUND

Medical malpractice is a very common occurrence that many medical providers will have to face; approximately 17,000 medical malpractice cases are filed in the United States each year, and more than 99% of all surgeons are faced with at least 1 instance of malpractice litigation throughout their careers. Malpractice litigation also carries a major economic weight, with medical malpractice spending resulting in an aggregate expenditure of nearly $60 billion annually in the United States. Orthopedic surgery is one of the most common subspecialties involved in malpractice claims. Currently, there are no comprehensive studies examining malpractice lawsuits within shoulder and elbow surgery. Therefore, the purpose of this work is to examine trends in malpractice claims in shoulder and elbow surgery.

METHODS

The Westlaw online legal database was queried in order to identify state and federal jury verdicts and settlements pertaining to shoulder and elbow surgery from 2010-2020. Only cases involving medical malpractice in which an orthopedic shoulder and elbow surgeon was a named defendant were included for analysis. All available details pertaining to the cases were collected. This included plaintiff demographic and geographic data. Details regarding the cases were also collected, such as anatomic location, pathology, complications, and case outcomes.

RESULTS

Twenty-five malpractice lawsuits pertaining to orthopedic shoulder and elbow surgery were identified. Most plaintiffs in these cases were adult men, and the majority of cases were filed in the Southwest (28%) and Midwest (28%) regions of the United States. The most common anatomic region involved in claims was the rotator cuff (32%), followed by the glenohumeral joint (20%). The majority of these claims involved surgery (56%). Pain of mechanical nature was the most common complication seen in claims (56%). The jury ruled in favor of the defendant surgeon in most cases (80%).

DISCUSSION

This is the first study that comprehensively examines the full scope of orthopedic shoulder and elbow malpractice claims across the United States. The most common complaint that plaintiffs reported at the time of litigation was residual pain after treatment due to a mechanical etiology, followed by complaints of nerve damage. A large portion of claims resulted after nonoperative treatment. A better understanding of the trends within malpractice claims is crucial to developing strategies for prevention.

Malpractice Allegations Against Vascular Surgeons:Prevalence, Risk Factors, and Impact on Surgeon Wellness

OBJECTIVES

The contemporary medicolegal environment has been linked to procedure overuse, healthcare variation, and higher costs. For physicians accused of malpractice, there is also a personal toll. The objective of this study was to evaluate the prevalence of and risk factors for involvement in medical malpractice lawsuits among US vascular surgeons, and to examine the association between these allegations with surgeon wellness.

METHODS

In 2018, the Society of Vascular Surgery (SVS) Wellness Task Force conducted a confidential survey of active members using a validated burnout assessment (Maslach Burnout Index) embedded into a questionnaire. This survey included questions related to medical errors and malpractice litigation. De-identified demographic, personal, and practice-related characteristics were assessed in respondents who reported malpractice allegations in the preceding two years, then compared to those without recent medicolegal litigation. Risk factors for malpractice allegations were identified (chi-square, Kruskal-Wallis tests), and the association between malpractice allegations with wellness was examined. Multivariate logistic regression models were developed to identify independent risk factors for malpractice accusations.

RESULTS

Of 2905 active SVS members, 871 responses from practicing vascular surgeons were analyzed. 161 (18.5%) were named in a malpractice lawsuit within two years. Malpractice allegations were significantly associated with surgeon burnout [OR 1.47 (1.01, 2.15), p=0.041], but not with self-reported depression or suicidal ideation. The nature of malpractice claims included procedural errors (23.1%), failure to treat (18.8%) and error/delay in diagnosis (16.9%). 20% of claims were settled prior to trial and 19% were dismissed. Defendant vascular surgeons reported a "fair" resolution in 26.4% of closed cases. By unadjusted analysis, factors significantly associated with recent malpractice claims included mean age (51.7+/-10.0 vs. 49.3+/-11.2; p=0.0044) and mean years in practice (18.0+/-10.7 vs. 15.2+/-11.8; p=0.0007). Multivariate analysis revealed independent variables associated with malpractice allegations, including on-call frequency (p=0.0178), recent medical errors (p=0.0189), and male surgeons (p=0.045).

CONCLUSIONS

Malpractice allegations are common for vascular surgeons and are significantly associated with surgeon burnout. Nearly 20% of survey respondents reported being named in a lawsuit within the preceding two years. Our findings underscore the need for SVS initiatives to provide counseling and peer support for vascular surgeons facing litigation.

Accessory veins related hand ischemia: A case series

INTRODUCTION

Arteriovenous fistula is considered as a lifeline for chronic kidney patients undergoing maintenance hemodialysis.

OBJECTIVE

To study the outcome of ligation of the accessory vein causing hyperperfusion and ischemia of the ipsilateral limb.

METHOD

ology: A single institution, single surgeon, in-hospital, retrospective case series of patients presented with alarm symptoms in postoperative period following arteriovenous fistula.

RESULTS

A total of 800 AVF were created between 2016 and 2019, out of which 6/800 (0.75 %) patients presented with alarm symptoms related to venous hypertension and underwent accessory vein ligation. All showed normal recovery with complete resolution of symptoms postoperatively.

CONCLUSION

Timely ligation of the accessory vein in patients with arteriovenous fistula with accessory vein related alarm symptoms showed salvage of lifeline and limb with no residual complications during follow-up.

Review of Malpractice Lawsuits in the Diagnosis and Management of Aortic Aneurysms and Aortic Dissections

OBJECTIVE

Aortic aneurysms and dissections are prevalent causes of morbidity and mortality. The management of aortic pathologies may be called into question in malpractice suits. Malpractice claims were analyzed to understand common reasons for litigation, medical specialties involved, patient injuries, and outcomes.

METHODS

Litigation cases in the Westlaw database from September 1st, 1987 to October 23 rd, 2019 were analyzed. Search terms included "aortic aneurysm" and "aortic dissection." Data on plaintiff, defendant, litigation claims, patient injuries, misdiagnoses, and case outcomes were collected and compared for aortic aneurysms, aortic dissections, and overall cases.

RESULTS

A total of 346 cases were identified, 196 involving aortic aneurysms and 150 aortic dissections. Physician defendants were emergency medicine (29%), cardiology (20%), internal medicine (14%), radiology (11%), cardiothoracic (10%) and vascular surgery (10%). Litigation claims included "failure to diagnose and treat" (61%), "delayed diagnosis and treatment" (21%), "post-operative complications after open repair" (10%) and "negligent post-operative care" (10%). Patients with aneurysms presented with abdominal (63%) and back pain (37%), while dissections presented with chest pain (78%), abdominal pain (15%), and shortness of breath (14%). Misdiagnoses included gastrointestinal (12%), other cardiovascular (9%), and musculoskeletal conditions (9%), but many were not specified (58%). Overall, 83% of cases were wrongful death suits. Injuries included loss of consortium (23%), emotional distress (19%), and bleeding (17%). In 53% of the cases, the jury ruled in favor of the defendant. 25% of cases ruled for the plaintiff. 22% of cases resulted in a settlement. The mean rewarded for each case was $1,644,590.66 (SD: $5,939,134.58; Range: $17,500-$68,035,462).

CONCLUSION

For aortic pathologies, post-operative complications were not prominent among the reasons why suits were brought forth. This suggests improvements in education across all involved medical specialties may allow for improved diagnostic accuracy and efficient treatment, which could then translate to a decrease in associated litigation cases.

Medical malpractice in heart transplantation from 1994 to 2019

BACKGROUND

Heart transplantation is a unique clinical intervention because it involves two separate parties, the donor and the recipient. This increases the potential for the legal liability of heart teams involved with heart transplantation, but there is no research that exists to date that analyzes the etiology of medical malpractice litigations relating to heart transplantation.

METHODS

The Westlaw legal database was queried for all medical malpractice litigations concerning heart transplantation from 1994 to 2019 in the United States. Individual litigations were reviewed for inclusion, resulting in 41 included cases, and then analyzed for legal and clinical data. Statistical analyses were performed with the Fisher exact test and Mann-Whitney U tests.

RESULTS

The mean age of patients involved in these litigations was 38.88 years, with female patients being younger on average. Female patients received a significantly larger average award than male counterparts (p = .03). Alleged failure to diagnose was significantly associated with settlements (p = .047). An alleged failure to obtain informed consent as presented by the plaintiff was significantly associated with defendant verdicts (p = .03). Incidence of stroke and infection were each significantly associated with nondefendant verdicts (p = .02 and p = .02).

CONCLUSIONS

There should be an emphasis on documenting informed consent from all involved parties in heart transplantation to limit litigations filed against clinicians. As technologies and growing donor pools increase the prevalence of heart transplantation, clinicians would be well-served to be aware of legally tenable practices that will allow them to adopt a higher transplant volume without simultaneously adopting added legal exposure.

Comparison of transcutaneous oximetry with symptoms and arteriography in thoracic outlet syndrome

BACKGROUND

Non-invasive tests are still required to improve the holistic diagnostic approach of thoracic outlet syndrome (TOS).

OBJECTIVES

We aimed to analyze the diagnostic accuracy of the decrease from rest oxygen pressure (DROP) index of transcutaneous oximetry (TcpO2) in TOS.

METHODS

Seventy-six patients and 40 asymptomatic volunteers (Controls) were enrolled. In TOS-suspected patients, the arteriograms were investigated for the presence of≥75% stenosis. The area under receiver operating characteristics curve (AUC) analysis tested the ability of forearm TcpO2 during provocative maneuvers to discriminate patients from controls and, to predict a positive arteriographic findings in the 44 TOS-suspected patients that had an arteriography.

RESULTS

The media [25/75° centile] DROP values of controls and patients were -14 [-8/-22] mmHg and -22 [-12/-42] mmHg, respectively (p for Mann-Whitney<0.02). AUC analysis showed a significant ability of TcpO2 to predict the presence of subclavian arterial compression on arteriography (AUC, 0.694).

CONCLUSIONS

Although time consuming, tcpO2 is independent of the observer expertise and could be useful in TOS-suspected patients to select the patients that should undergo arteriography.

Malpractice Litigation for Compartment Syndrome

BACKGROUND

The aim of this study was to analyze litigation involving compartment syndrome to identify the causes and outcomes of such malpractice suits. A better understanding of such litigation may provide insight into areas where clinicians may make improvements in the delivery of care.

METHODS

Jury verdict reviews from the Westlaw database from January 1, 2010 to January 1, 2018 were reviewed. The search term "compartment syndrome" was used to identify cases and extract data on the specialty of the physician defendant, the demographics of the plaintiff, the allegation, and the verdict.

RESULTS

A total of 124 individual cases involving the diagnosis of compartment syndrome were identified. Medical centers or the hospital was included as a defendant in 51.6% of cases. The most frequent physician defendants were orthopedic surgeons (45.96%) and emergency medicine physicians (20.16%), followed by cardiothoracic/vascular surgeons (16.93%). Failure to diagnose was the most frequently cited claim (71.8% of cases). Most plaintiffs were men, with a mean age of 36.7 years, suffering injuries for an average of 5 years before their verdict. Traumatic compartment syndrome of the lower extremity causing nerve damage was the most common complication attributed to failure to diagnose, leading to litigation. Forty cases (32.25%) were found for the plaintiff or settled, with an average award of $1,553,993.66.

CONCLUSIONS

Our study offers a brief overview of the most common defendants, plaintiffs, and injuries involved in legal disputes involving compartment syndrome. Orthopedic surgeons were most commonly named; however, vascular surgeons may also be involved in these cases because of the large number of cases with associated arterial involvement. A significant percentage of cases were plaintiff verdicts or settled cases. Failure to diagnosis or delay in treatment was the most common causes of malpractice litigation. Compartment syndrome is a clinical diagnosis and requires a high level of suspicion for a timely diagnosis. Lack of objective criteria for diagnosis increases the chances of medical errors and makes it an area vulnerable to litigation.

Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke

Background and Purpose—

The emergency management of stroke is complex and highly time-sensitive. Recent landmark trials demonstrating the strong benefit of thrombectomy have led to rapid change in stroke management. This article reviews a large number of medical malpractice lawsuits related to the emergency management of stroke to characterize factors involved in these lawsuits.

Methods—

Three large legal databases were used to search for jury verdicts and settlements in cases related to the acute care of stroke patients in the United States. Search terms included “stroke” and “medical malpractice.” Cases were screened to include only cases in which the allegation involved negligence in the acute care of a patient suffering a stroke.

Results—

We found 246 medical malpractice cases related to the acute management of ischemic stroke and 26 related to intracranial hemorrhage. Seventy-one cases specifically alleged a failure to treat with tPA (tissue-type plasminogen activator) and 7 cases alleged a failure to treat, or to timely treat, with thrombectomy. Overall there were 151 cases (56%) which ended with no payout, 74 cases (27%) were settled out of court, and 47 cases (17%) went to court and resulted in a verdict for the plaintiff. The average payout in settlements was $1 802 693, and the average payout in plaintiff verdicts was $9 705 099.

Conclusions—

Malpractice litigation is a risk in acute stroke care and can lead to significant financial consequences. The majority of malpractice lawsuits related to the emergency management of stroke allege a failure to diagnose and failure to treat. Allegations of a failure to treat acute ischemic stroke with tPA were frequently found and are common in lawsuits. Allegations of a failure to treat a large vessel occlusion with thrombectomy were less frequently found. Given recent changes in practice guidelines and the demonstrated strong treatment effect of thrombectomy, it is likely that such litigation will increase in the coming years.

Jury verdicts and outcomes of malpractice cases involving arteriovenous hemodialysis access

OBJECTIVE

To analyze malpractice cases involving hemodialysis access to prevent future litigation and improve physician education.

METHODS

Jury verdict reviews from the WESTLAW database from 1 January 2005 to 1 January 2015 were reviewed. The search terms "hemodialysis," "dialysis," "graft," "fistula," "AVG," "AVF," "arteriovenous," "catheter," "permacatheter," and "shiley" were used to compile data on the demographics of the defendant, plaintiff, allegation, complication, and verdict.

RESULTS

Sixty-six cases involving the litigation pertaining to hemodialysis catheter, arteriovenous fistula (AVF) or arteriovenous grafts (AVGs) were obtained. Of these, 55% involved catheter-based hemodialysis access, 18% involved AVF, and 27% involved AVG. The most frequent physician defendants were vascular surgeons (36%), internists (14%), nephrologists (14%), general surgeons (9%), and interventional radiologists (6%). Of the patients, 38% involved were male and the average patient age was 56.3 (standard deviation (SD) = 20.1) years. Region of injury was 50% in the neck or chest, 42% in the arm, and 8% in the groin. Injury was listed as death in 79% of cases. Of the deaths, 95% involved bleeding at some point in the chain of events. The most common claims related to the cases were failure to perform the surgery or procedure safely (44%), failure to diagnose and treat in a timely manner (30%), and negligent hemodialysis treatment (11%). The most common complications cited were hemorrhage (62%), loss of function of limb (15%), and ischemia due to steal syndrome (11%). A total of 26 cases (39%) were found for the plaintiff or settled. The median award was US$463,000 with a mean of US$985,299 (SD = US$1,314,557).

CONCLUSION

While popular opinion may indicate that steal syndrome is a commonly litigated complication, our data reveal that the most common injury litigated is death which may frequently be the result of a hemorrhagic episode. In addition to hemorrhage, the remaining most common complications included steal syndrome and loss of limb function. Therefore, steps to better prevent, diagnose and treat bleeding, nerve injury, and steal syndrome in a timely manner are critical to preventing hemodialysis-access-associated litigation.