The Current State of Medical Malpractice in Urology

Legal Outcomes of Litigation After Iatrogenic Genitourinary Trauma

OBJECTIVE

To evaluate plaintiff and defendant characteristics associated with iatrogenic genitourinary (GU) trauma litigation and outcomes of closed claims.

METHODS

LexisNexis was queried in April 2023 using terms related to GU organs and injury, and manually reviewed for iatrogenic cases. Case details including defendant, organ involvement, and legal outcome were obtained. Multinomial regression analysis was performed to identify factors associated with outcome.

RESULTS

Four hundred ten cases involving 611 defendants were identified, with the ureter the most commonly affected organ (202/410, 49.3%). Most cases involved adult plaintiffs (380, 92.7%) and resulted in favor of the defense (227, 55.4%). Injuries resulted most frequently from gynecologic surgeries (179, 43.7%). Defendants were most commonly obstetricians/gynecologists (243/611, 39.8%) and urologists (168, 27.5%). Penile (OR 6.3 [95% CI 2.5-16.1]) and urethral (OR 4.8 [2.0-11.7]) injuries were associated with greater odds of a plaintiff verdict relative to ureter injury. A plaintiff verdict was also more likely when defendants were academic hospitals compared to individual practitioners (OR 4.3 [1.9-9.9]). In cases ruling in favor of the plaintiff, indemnity payments were larger when the defendants were comprised of individual practitioners compared to a hospital or medical group (median $549,613 vs $250,000, P <.001).

CONCLUSION

Urologists may be involved in medical malpractice lawsuits for iatrogenic injury even when they are uninvolved in the index procedure. Most cases that reach litigation result in defense verdicts regardless of the GU organ injured. Defendant characteristics associated with plaintiff verdicts are more nuanced, and providers should be aware of potential downstream effects of litigation.

Bladder exstrophy-epispadias complex related litigation: A legal database review

OBJECTIVE

To review the nature and extent of bladder exstrophy-epispadias related malpractice litigation in the United States.

METHODS

Two legal databases (Nexis Uni, WestLaw) were reviewed for state and federal cases using the terms "bladder exstrophy", "cloacal exstrophy", "epispadias", in combination with "medical malpractice", or "negligence", or "medical error", or "complication", or "malpractice", or "tort". Databases were queried from 1948 to 2022 and reviewed for medical and legal details.

RESULTS

Our search yielded 16 unique legal cases with 6 fitting established criteria for analysis. Urology and paediatric urologists were named in 50% of cases as were community medical systems. Cause for lawsuit included negligence in surgical performance (50%), primary closure of exstrophy (33%), and post-operative care (50%). Settlement agreement was reached in one case (17%). Outcomes favoured the physician in 60% of trials. Lawsuits alleging negligent surgical performance and/or post-operative care exclusively named urologists with outcomes favouring the surgeon in 66% of cases. The settlement payment (n = 1) was $500,000 and monetary damages (n = 1) equated to $1.3 million.

CONCLUSIONS

Malpractice litigation related to BEEC treatment is rare. Trial outcomes favour the medical provider. Cases that resulted in financial liability successfully alleged avoidable negligence resulting in irreversible physical damage. The authors recommend families with BEEC seek board-certified paediatric urologists experienced in treating this complex and/or Bladder Exstrophy Centers of Excellence. Further, we recommend surgeons treating BEEC properly educate patients and families on the severity of this major birth defect including its lifelong implications and need for surgical revisions.

A 9-year analysis of medical malpractice litigations in coronary artery bypass grafting in China

BACKGROUND

The coronary artery bypass grafting (CABG) is one of the high-risk litigated medical specialties. Further elucidating the causes behind these malpractice claims can help physicians avoid patient injury. This study analyzed CABG litigations occurred in different level hospitals to outline the basic characteristics, as well as present a analysis on the medical malpractice that result in lawsuits.

METHODS

This study utilized the "China Judgments Online" database to compile litigations from 2012 to 2021 across China. 109 cases related to the CABG were included in the study, and were analyzed for demographic, patient outcomes and verdict characteristics in different levels of hospitals.

RESULTS

The median age of plaintiff patient was 62 years, the median length of stay was 25 days, and the median responsibility ratio of the litigation cases was 30%. The average proportion of responsibility of national, provincial and municipal hospitals were 29.6%, 28.4% and 39.5% respectively, and the median days after surgery to death of that were 15, 9 and 5 separately. The top 5 postoperative complications in dispute cases were: low cardiac output syndrome, postoperative hemorrhage, non-surgical site infections, surgical site infections and arrhythmia.

CONCLUSIONS

The diagnosis and treatment capabilities of coronary artery bypass grafting in different levels of hospitals in China were inconsistent, and the treatment capabilities in prefecture-level hospitals were lower than that in national hospitals. The procedural error, failure to properly monitor the patient and diagnostic errors were common in CABG litigations. Postoperative complications related to surgical injuries and insufficient basic postoperative management lead to a higher responsibility proportion.

Medical Malpractice Lawsuits Involving Urology Trainees

OBJECTIVES

To distinguish the various characteristics of medical malpractice lawsuits involving trainees to prevent future litigation.

METHODS

LexisNexis, an online legal research database containing legal records from the United States, was retrospectively reviewed for malpractice cases involving urology interns, residents, or fellows from January 1, 1988, to December 31, 2020.

RESULTS

A total of 16 cases were included, of which 7 (43.8%) involved urological allegations while 9 (56.2%) involved non-urological allegations. Five of the cases consisting of non-urological adverse outcomes led to mortality. Procedural error was claimed in 12 (75.0%) cases, negligence in 7 (43.8%), delayed evaluation in 6 (37.5%), lack of informed consent of procedure or complications in 5 (31.2.%), failure to pursue treatment in 4 (25.0%), inexperienced trainee in 2 (12.5%), failure to supervise trainee in 2, lack of informed consent of trainee involvement in 1, incorrect diagnosis in 1, and prolonged operative time in 1 case.

CONCLUSIONS

Malpractice education, careful supervision, awareness during perioperative care, and detailed communication between patients and physicians should be highlighted in training programs to improve patient outcomes and mitigate risk of future malpractice.

5-Alpha reductase inhibitor related litigation: A legal database review

BACKGROUND

5α-reductase inhibitors are commonly prescribed medications with multiple side effects used in the treatment of male pattern hair loss and benign prostatic hyperplasia. These side effects including "post-finasteride syndrome" may result in lawsuits.

OBJECTIVES

To characterize lawsuits involving the adverse side effects of 5α-reductase inhibitor to better understand drivers of litigation and outcomes.

METHODS

Legal cases were queried from Nexis Uni using the search terms "5-alpha reductase inhibitor" as well as specific agents "finasteride," "dutasteride" in combination with "malpractice," "negligence," "damage," "loss," "side effect," and "complication." Secondary review was performed with publicly available data on "In Re: Propecia." Relevant cases were reviewed and pertinent characteristics were extracted and summarized using descriptive statistics.

RESULTS

Our search yielded 156 unique legal cases in the Nexis Uni database from April 2003 to May 2021. Only 18 of these cases met the inclusion criteria. Adverse events experienced by patients included medication side effects (n = 12, 66.7%), delayed cancer diagnosis (n = 3, 16.7%), and lack of symptom improvement (n = 3, 16.7%). The identity of the plaintiffs were most commonly patients themselves (n = 15, 83.3%). Defendants include pharmaceutical companies (n = 6, 33.3%), a combination of parties (n = 5, 27.8%), and physicians (n = 5, 27.8%) alone. The allegations included sexual side effects such as erectile dysfunction (n = 6, 33.3%) and decreased libido (n = 4, 22.2%). These prescriptions were made for benign prostatic hyperplasia (n = 9, 50%), male pattern hair loss (n = 7, 38.9%), and feminizing hormone therapy (n = 2, 11.1%). Several of these cases involved the same plaintiffs in related cases. No verdicts were against physicians. We noted a largely settled lawsuit involving more than 1000 plaintiffs with limited data on harms alleged and a $4.3 million settled amount. Of the total cases that resulted in a verdict, 9/18 were within the last 3 years.

DISCUSSION

The most common complications experienced by patients in our legal review were those involving sexual dysfunction with erectile dysfunction and decreased libido. The growing number of cases in the later years of our review suggests litigation may continue to increase in the coming future. Our review did not identify any individual cases that resulted in a monetary payout beyond a $4.3 million settlement outside of court.

CONCLUSION

5α-reductase inhibitor was alleged to have sexual, mental, and physical side effects, resulting in legal litigation. Despite this, no judgment against a physician or pharmaceutical company was identified. We do note and discuss a large number of lawsuits settled out of court. Given the increase in the number of lawsuits resulting in verdicts over the last 3 years, we suspect that the frequency of litigation around 5α-reductase inhibitors will continue for the foreseeable future.

A Legal Database Review of Circumcision Related Litigation in the United States

OBJECTIVE

To characterize circumcision-related litigation in the United States (US) and factors predictive of lawsuit outcome. Circumcision is a common urologic procedure with medical and ethical nuances.

METHODS

We reviewed the Nexis Uni legal database for state and federal cases using the term "circumcision" in combination with "medical malpractice" or "negligence" or "medical error" or "complication" or "malpractice" or "tort". Litigation primarily related to circumcision from 1939 to 2021 were reviewed for medical and legal details.

RESULTS

We identified 77 unique cases. Most cases were processed in state (87%) or appellate (59%) court systems with negligent surgical performance as the most common lawsuit reason (49%). Of reported specialties, urology was the highest proportion represented among named physicians (29%) and most patients were minors at time of circumcision (64%) and lawsuit (59%). Common complications included aesthetic dissatisfaction (20%), pain (19%), impaired sexual function (17%) and surgical trauma/injury (16%). Most verdicts favored physicians (59%), but when against physicians, the median indemnity was $175,000. Lawsuits due to negligent informed consent were significantly more likely to result in verdict favoring the physician compared to those due to negligent surgical performance.

CONCLUSIONS

Circumcision-related litigation in the US is rare and trial verdicts favor physicians, particularly in federal court cases or when parties allege negligent informed consent. Cases that favored plaintiffs successfully alleged negligent surgical technique. We recommend physicians performing circumcisions receive proper training, clearly communicate potential complications, and ensure appropriate indications for adult patients to reduce malpractice risk.

Medical malpractice in stress urinary incontinence management: A 30-year legal database review

BACKGROUND

The purpose of this study is to investigate the most common reasons for and judicial outcomes of malpractice claims related to stress urinary incontinence (SUI) management.

MATERIALS AND METHODS

Using the Westlaw database, a search was performed using the terms "medical malpractice" or "negligence" in combination with "stress incontinence" or "stress urinary incontinence" between January 1, 1990 and January 1, 2020. Extracted information included trial date, demographic information, defendant profession, procedure performed, procedure complications, alleged malpractice, trial outcome, and monetary award. Data were analyzed using descriptive statistics.

RESULTS

The Westlaw search yielded 79 case results. Of the cases, 70.4% (n = 38/54) had a defense verdict, 22.2% (n = 12/54) had a plaintiff verdict, and 7.4% (n = 4/54) were settled. The most commonly implicated procedure was mid-urethral sling (63.2%, n = 36/57). Among the plaintiffs, 48.4% (n = 61/126) claimed negligence in preoperative care, 33.3% (n = 42/126) claimed negligence in surgical performance, and 18.3% (n = 23/126) claimed negligence in postoperative care. Lack of informed consent was the most common complaint related to negligence in preoperative care (42.6%, n = 26/61). The average indemnity payment was $1,253,644 for preoperative care negligence, $1,254,491 for surgical performance negligence, and $2,239,198 for postoperative care negligence. Of the defendants, 63.4% (n = 52) were gynecologists and 36.6% (n = 30) were urologists.

CONCLUSIONS

Negligent preoperative care, with a particular emphasis on failure to obtain informed consent, and negligent surgical performance are the leading causes of malpractice claims during SUI management. Mid-urethral sling was the most commonly litigated procedure. This study highlights key factors to consider in minimizing malpractice risk during SUI management.

Medical Malpractice in Nerve Injury of the Upper Extremity

Background: Medical malpractice accounts for more than $55 billion of annual health care costs. Updated malpractice risk to surgeons and physicians related to upper extremity peripheral nerve injury has not been published. Methods: A comprehensive database analysis of upper extremity nerve injury claims between 1995 and 2014 in the United States was conducted using the Medical Professional Liability Association Data Sharing Project, representing 24 major insurance companies. Results: Nerve injury in the upper extremity accounted for 614 (0.3%) malpractice claims (total of 188 323). Common presenting diagnoses included carpal tunnel syndrome (41%), upper extremity fractures (19%), and traumatic nerve injuries to the shoulder or upper limb (8%). Improper performance (49% of total claims) and claims without evidence of medical error (19%) were the most common malpractice suits. Orthopedic surgeons were the most frequently targeted specialists (42%). In all, 65% of nerve injury claims originated from operative procedures in a hospital, 59% of claims were dismissed or withdrawn prior to trial, and 30% resulted in settlements. Thirty-three percent of claims resulted in an indemnity payment to an injured party, with an average payout of $203 592 per successful suit. Only 8% of claims resulted in a completed trial and verdict, and verdicts were overwhelmingly in favor of the defendant (83%). Conclusions: Most malpractice claims from peripheral nerve injuries in the United States arise from the management of common diagnoses, occur in the operating room, and allege improper performance. Strategies to reduce malpractice risk should emphasize the management of common conditions and patient-physician communication.

Litigation Patterns in Oncologic Nephrectomies: A 30-Year Review

Introduction: The litigious environment encompassing the medical-legal domain is an increasing concern for surgical fields, with urology being no exception. The objective of our study was to systematically review, evaluate, and summarize the factors associated with oncologic nephrectomy litigation to determine possible factors contributing to verdicts or settlements. Materials and Methods: Publicly available verdict reports were retrieved using the Westlaw^® legal database (Reuters). Cases were identified using the search term "nephrectomy" with dates ranging from January 1, 1990 to July 1, 2019. Each case was evaluated by two independent reviewers for defendant specialty, alleged breach in treatment, resulting complications, verdict outcomes, and indemnity payment. Complications were determined to be preoperative, perioperative, and postoperative. Data were analyzed using SPSS software to produce the descriptive statistics. Results: After accounting for duplicates and irrelevant cases, a total of 103 cases were analyzed with more than three-fourths being radical nephrectomies (78%). The most common claim was preoperative negligence (48%); however, negligence in perioperative care received the highest average monetary payment of $5,493,151. Forty-one percent of cases were perioperative with the majority being attributed to vascular injury (46%). The type of perioperative negligence claims and its average payment were found to be statistically significant (p = 0.042). Overall, 57% of cases denied the plaintiff's claims, whereas 28% were awarded. Conclusions: Our data show that although the highest number of cases were caused by preoperative negligence, perioperative negligence accounts for the highest settlement awards. This review provides insights into stages of management in the surgical management of renal cell cancer patients that may be subject to litigation.

[Medico-legal risk in urology: Analysis of a portfolio of insured persons by a French insurance company between 2009 and 2018]

OBJECTIVE

Presentation of data collected on urology claims from the register of a French insurance company.

MATERIAL AND METHOD

Compensation claims involving urologists covering the period 2009-2018 were identified and analyzed.

RESULTS

A total of 37 files were found. Oncological and functional surgical interventions accounts for 78% of repair claims. Postoperative complications represent 76% of the cases. The most represented acts are total prostatectomy (5) and promonto-fixation (4). The average time of complaint is 28.6 months [1-144 months], the average duration of a procedure (opening-closing) is 32.8 months [12-72 months]. The Conciliation and Compensation Commissions (CCC) and the High Court Courts (HCC) were solicited respectively in 51% and 33% of the proceedings. An amicable agreement is found in 16% of cases. There was no criminal or disciplinary proceedings. The average cost of a closed urology file is 7836 € [0-31,120 €]. In total, 64.8% of the expertises confirm practices in the respect of the rules of the art.

CONCLUSION

This series presents the first forensic analysis of a portfolio of urologists on a period of 9 years in French urology. There is a rate of responsibility retained against the practitioner in only 27% of cases. The low rate of faulty files, the absence of a conviction for breach of the duty to provide information and in connection with antibiotic prophylaxis seem to confirm that the practice of urology in France is of good quality, a further study on a longer period of time and on a larger cohort of urologists would allow a finer medico-legal approach.

LEVEL OF EVIDENCE

3.

Analysis of closed medical litigation in urology

PURPOSE

The objective of this study was to provide a descriptive understanding of the characteristics of malpractice litigation related to urology by examining court cases.

MATERIALS AND METHODS

A total of 6,074 court cases related to medical malpractice litigation filed between 2005 and 2010 were received from the Lower Courts, the Appellate Courts, and the Supreme Court of Korea. Of the received cases, 34 urology-related civil proceedings were analyzed. The following information was compiled and investigated from the cases: background, age and sex of patient, categorization of the defendant, opinion of the court, amount claimed and awarded in damages, type of medical treatment involved, and negative effects resulting from the medical accident.

RESULTS

The average amount in damages paid out to plaintiffs in this research was 27,186,504±32,371,008 Korean won (KRW) (range, 1,000,000-100,000,000 KRW). A total of 9 of the 34 analyzed cases (26.5%) ruled in favor of the plaintiff, with all 9 cases involving a surgery. An analysis of the surgery sites further revealed that the penis was the most frequently litigated over site of surgery, making up 14 of the 35 sites (40.0%).

CONCLUSIONS

Information regarding urology malpractice lawsuits should be made available to help prevent further disputes and litigation. Continuous efforts must be expended in the prevention of accidents and disputes, alongside research into urology-related cases beyond 2010. Extensive cause analysis and recurrence prevention methods must also be researched to enhance overall patient safety.

Urological Malpractice: Claim Trend Analysis and Severity of Injury

INTRODUCTION

In the current malpractice environment all urologists are at risk. Claim trend data on costs, types of urological errors and severity of injury in urological surgery malpractice claims are lacking.

METHODS

We analyzed physician level claim data from a large professional liability insurer with a nationwide client base. Available data included records on closed malpractice claims from 1985 to 2013. We evaluated insured demographics, total number of closed claims, costs of indemnity payments, costs of defense, types of errors resulting in closed claims and severity of injury in urological claims.

RESULTS

Compared to other medical specialties urology ranks 13th in total claims and 15th in average cost of indemnity payments in the last decade. Most urological claims are dropped, dismissed or withdrawn without indemnity payment. Of closed urological claims 27.2% result in an indemnity payment to the plaintiff. Adjusting for inflation, urological indemnity payments have increased by 60% since the 1980s and average payouts are now greater than $350,000. Improper performance of a procedure is the most prevalent urological error resulting in closed claims (875 closed claims in the last decade). Procedures involving the kidney (245 closed claims) and prostate (244 closed claims) are most frequently implicated. The majority of urological errors result in temporary or minor permanent injury. Errors resulting in grave injury are the most costly, with average indemnity payments of $514,844.

CONCLUSIONS

Awareness of claim trends and errors implicated can help urologists better understand the current malpractice environment.

Urethral catheters and medical malpractice: a legal database review from 1965 to 2015

Background

Urethral catheters (UCs) are commonly used in medicine and are associated with complications such as urinary tract infections (UTIs) and trauma. Given UC complications and their ubiquitous usage in healthcare, there is a potential for liability risk. We aim to explore litigation involving UC-related complications.

Methods

The LexisNexis legal database was queried for all state and federal cases from January 1965 through October 2015 using the terms “urethral catheter” or “Foley catheter” in combination with “medical malpractice”, “negligence”, “medical error”, and “trauma”. Each case was reviewed for reported medical characteristics and legal aspects, including the outcome of the case.

Results

Our search yielded 29 cases. Urologists were the most common providers cited as defendants (21%), all of whom were successful in their defense. The most common malpractice claim was for traumatic insertion (48%). Pain was the most common type of damage claimed by plaintiffs (28%), followed by UTI (24%). Nineteen (66%) cases favored defendants, while 10 (34%) cases favored the plaintiffs, of which 2 (7%) were settled out of the court. In settled cases, the mean settlement received by plaintiffs was $55,750 (range, $25,000–$86,500). The mean award to plaintiffs for cases determined by the court was $112,991 (range, $4,000–$325,000).

Conclusions

Despite widespread usage of UC over a 50-year period, lawsuits centered on UC misuse are rare at the state and federal court levels. Of litigated cases, urologists are commonly involved yet have successful defenses.