Malpractice risk: trauma care versus other surgical and medical specialties

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.

Increased litigation burden among tibia, pelvis, and spine fractures: An analysis of 756 fracture-related malpractice cases

Objectives:

To analyze a series of claims from a large national malpractice insurer associated with fracture care to understand what parameters are associated with claims, defense costs, and paid indemnity.

Design:

Review of claims in fracture care settings from a national database; case series.

Setting:

Database draws from insured pool of 400,000 medical malpractice cases from 400 healthcare entities across the country, representing 165,000 physicians; both academic and private.

Patients/Participants:

Fracture care patients bringing legal suit.

Main Outcome Measurements:

Cost of legal proceedings and indemnity, ICD-9 codes, and contributing causes toward claims.

Results:

A total of 756 fracture claims were asserted between 2005 and 2014 regarding fracture care within the database; 70% were brought for inaccurate, missed, or delayed diagnosis, while 22% addressed medical treatment and 8% were for surgical management. Orthopaedics was the primary service in 22%. Total cost (expenses and indemnity) to orthopaedic providers totaled $13.1MM (million). The most common claim against orthopaedics was for fractures of the tibia and fibula (11.4%). Impact factor (IF) analysis (as described by Matsen) of indemnity in these cases reveals 3 fracture regions of highest indemnity burden: fractures of the tibia and fibula (IF: 1.86, 11.4%), pelvis (IF: 1.77, 6.6%), and spine (IF 1.33, 6.6%). Analysis of contributing factors identifies the category of clinical judgement as the most common category (62%). Other common factors include patient noncompliance (31%), communication (28%), technical skill (17%), clinical systems (11%), and documentation (10%). The single most common specific cause of a claim in orthopaedic fracture care was misinterpretation of diagnostic imaging (25%).

Conclusion:

This study is the first of its kind to identify fractures of the tibia and fibula as high risk for litigation against orthopaedic providers and provides general counseling of legal pitfalls in fracture care. Finally, we are able to identify the act of patient assessment as a key issue in over half of all fracture-related claims against orthopaedic providers. Providers in general and specialty settings can use this information to help guide their treatment and care ownership decisions in the care of patients with fractures.

Level of Evidence:

Economic - Level III.

High and low-risk specialties experience with the U.S. medical malpractice system

Background

“High-liability risk specialties” tend to be the focus of medical malpractice system research and debate, but concerns and fears are not limited to this group. The objective of this study was to examine whether “high-liability risk” medical specialties have a different experience with the malpractice system than “low-liability risk” specialties.

Methods

We reviewed claims data from the Physician Insurers Association of America’s Data Sharing Project between January 1985 and December 2008. We used linear regression, controlling for year, to determine how liability risk affected outcomes of interest.

Results

In high-liability risk specialties, 33% of claims result in indemnity payments compared to 28% for low-liability risk specialties (p < 0.001). The average indemnity payment for high-liability risk specialties was $315,314 compared to $267,146 for low-liability risk specialties (p = 0.25). Although only a small percentage of claims go to trial, low-liability risk specialties have significantly more claims that are ultimately dropped, withdrawn or dismissed, while high-liability risk specialties have significantly more claims that result in plaintiff settlement (p < 0.001).

Conclusions

Malpractice risk exists for all specialties. Variability in indemnity costs are found in both high- and low-liability risk specialties. Differences in the reasons for which claims are initiated for high- and low-liability risk specialties likely necessitate different risk management solutions.

Professional liability in orthopaedics and traumatology in Italy

BACKGROUND

Interest in medical errors has increased during the last few years owing to the number of medical malpractice claims. Reasons for the increasing number of claims may be related to patients' higher expectations, iatrogenic injury, and the growth of the legal services industry. Claims analysis provides helpful information in specialties in which a higher number of errors occur, highlighting areas where orthopaedic care might be improved.

QUESTIONS/PURPOSES

We determined: (1) the number of claims involving orthopaedics and traumatology in Rome; (2) the risk of litigation in elective and trauma surgery; (3) the most common surgical procedures involved in claims and indemnity payments; (4) the time between the adverse medical event and the judgment date; and (5) issues related to informed consent.

METHODS

We analyzed 1925 malpractice judgments decided in the Civil Court of Rome between 2004 and 2010.

RESULTS

In total, 243 orthopaedics claims were filed, and in 75% of these cases surgeons were found liable; 149 (61%) of these resulted from elective surgery. Surgical teams were sued in 30 claims and found liable in 22. The total indemnity payment ordered was more than €12,350,000 (USD 16,190,000). THA and spinal surgery were the most common surgical procedures involved. Inadequate informed consent was reported in 5.3% of cases.

CONCLUSIONS

Our study shows that careful medical examination, accurate documentation in medical records, and adequate informed consent might reduce the number of claims. We suggest monitoring of court judgments would be useful to develop prevention strategies to reduce claims.

Clinical errors and medical negligence

This paper discusses the definition, nature and origins of clinical errors including their prevention. The relationship between clinical errors and medical negligence is examined as are the characteristics of litigants and events that are the source of litigation. The pattern of malpractice claims in different specialties and settings is examined. Among hospitalized patients worldwide, 3-16% suffer injury as a result of medical intervention, the most common being the adverse effects of drugs. The frequency of adverse drug effects appears superficially to be higher in intensive care units and emergency departments but once rates have been corrected for volume of patients, comorbidity of conditions and number of drugs prescribed, the difference is not significant. It is concluded that probably no more than 1 in 7 adverse events in medicine result in a malpractice claim and the factors that predict that a patient will resort to litigation include a prior poor relationship with the clinician and the feeling that the patient is not being kept informed. Methods for preventing clinical errors are still in their infancy. The most promising include new technologies such as electronic prescribing systems, diagnostic and clinical decision-making aids and error-resistant systems.