Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety

Beyond medical errors: exploring the interpersonal dynamics in physician-patient relationships linked to medico-legal complaints

BACKGROUND

Previous research suggests that medico-legal complaints often arise from various factors influencing patient dissatisfaction, including medical errors, physician-patient relationships, communication, trust, informed consent, perceived quality of care, and continuity of care. However, these findings are not typically derived from actual patients' cases. This study aims to identify factors impacting the interpersonal dynamics between physicians and patients using real patient cases to understand how patients perceive doctor-patient relational problems that can lead to dissatisfaction and subsequent medico-legal complaints.

METHODS

We conducted a retrospective study using data from closed medical regulatory authority complaint cases from the Canadian Medical Protective Association (CMPA) between January 1, 2015, and December 31, 2020. The study population included patients who experienced sepsis and survived, with complaints written by the patients themselves. A multi-stage standardized thematic analysis using Braun and Clarke's approach was employed. Two researchers independently coded the files to ensure the reliability of the identified codes and themes.

RESULTS

Thematic analysis of 50 patient cases revealed four broad themes: (1) Ethics in physician's work, (2) Quality of care, (3) Communication, and (4) Healthcare system/policy impacting patient satisfaction. Key sub-themes included confidentiality, honesty, patient involvement, perceived negligence, perceived lack of concern, active engagement and empathy, transparency and clarity, informed consent, respect and demeanor, lack of resources, long wait times, and insufficient time with physicians.

CONCLUSIONS

This study identifies and categorizes various factors impacting relational issues between physicians and patients, aiming to increase patient satisfaction and reduce medico-legal cases. Improving physicians' skills in areas such as communication, ethical practices, and patient involvement, as well as addressing systemic problems like long wait times, can enhance the quality of care and reduce medico-legal complaints. Additional training in communication and other skills may help promote stronger relationships between physicians and patients.

A qualitative review of challenges in recruitment and retention in obstetrics and gynecology in Ireland: The consultants' solution based perspective

AIM

Recruitment and retention remains a concern in obstetrics and gynecology, with consultants having a unique perspective on the daily challenges. We aimed to examine these and examine their solutions to future-proofing the workforce.

METHODS

Primary data were collected from consultant obstetrician-gynecologists in the Republic of Ireland. Using a qualitative methodology, semi-structured interviews were conducted with 17 participants recruited through purposive sampling. Following transcription, deductive content analysis was conducted to identify themes and categories with respect to challenges and solutions in the specialty.

RESULTS

Findings revealed four superordinate themes of professional and personal factors, opinions of the specialty and the role of the consultant. Respondents expressed fear about low morale in the specialty, but also threats posed by resource availability and training limitations, in addition to medico-legal and media challenges. Solutions centered around re-evaluating training pathways and implementing improved advocacy and support structures for the specialty and for those working within it.

CONCLUSIONS

This study provides a unique standpoint from which to explore an international in obstetrics and gynecology. Its solution-based outlook provides the framework to implement changes to protect and retain the current workforce as well as future-proofing recruitment to secure the specialty.

The National Practitioner Database Malpractice Study of Severity of Alleged Malpractice Injuries Trends 2008-2018

This research examined trends and severity of alleged injury in malpractice over a 10-year period. An understanding of the severity of patient outcomes is important to gauge improvements in care delivery. Analysis of the National Practitioner Database (NPDB) investigated malpractice payments from 2008 to 2018 by physicians, advanced nurse practitioners, and registered nurses and assessed the relationship of years of practice on the severity of alleged malpractice injury. Malpractice payments over the study period, primarily represented payments for significant permanent or major permanent injuries (25.97%) or death (32.74%). Claims overall have shown a decline, including claims by the severity of malpractice injury, for most outcomes. The clinicians represented in the NPDB with >15 years of practice have greater odds for severity of malpractice injuries classified as minor permanent injury and significant permanent injury than those clinicians represented in the NPDB with fewer years of practice. Top allegation categorizations for malpractice payment were diagnostics, treatment, and surgery related for 4 of the severities of alleged injury.

Why Are Patients Unhappy with Their Healthcare? A Romanian Physicians’ Perspective

Background: Medical professional liability complaints are not triggered by a single factor, but rather by multiple factors, each having more or less implications, such as the characteristics of the physician, the medical system, the patients, the complexity of their pathology, and the inherent limits of medicine. Knowledge about the factors that initiate the complaint procedure is essential to identify the targeted measures to limit their prevalence and impact. The purpose of this study was to identify the reasons behind the malpractice complaints and the factors that may influence the initiation of complaints by the patients. Material and Methods: This study was conducted using an online questionnaire, addressed to Romanian doctors, with questions about the reasons for patient dissatisfaction and complaints, the factors that predispose a physician to being complained against, and the protective factors against patient complaints. Results: The study group included 1684 physicians, of whom 16.1% were themselves involved in a complaint, and 52.5% knew of a colleague who was complained against. The opinions of the participants regarding the reasons for the complaints, the predisposing factors to complaints, and the factors that contributed to the reported incident showed a strong link between professional liability complaints and the physician–patient/patient’s family relationship. The relationship between fellow physicians is additional to this. Conclusion: This study reveals that the improvement in the relational aspects of medical practice (physician–patient relationship and relationship between physicians) has the highest potential to decrease the number of malpractice complaints. Its practical relevance is related to the need for training physicians in the relational aspects of medical practice during academic years and throughout their career.

Second Victim Experience and Perception Discordance of the Colonoscopic Perforation

BACKGROUND

Perforation is the most serious adverse event of colonoscopy, but rarely considered from the view of colonoscopists' second victim experience and perception discordance between colonoscopists and patients.

AIMS

We aimed to evaluate colonoscopists' second victim experience and the perception discordance between colonoscopists and patients for the colonoscopic perforation.

METHODS

A survey for colonoscopic perforation was performed for the colonoscopists and outpatients who visited the university hospital between February 1, 2020, and April 30, 2020. The questionnaire included questions regarding colonoscopists' satisfaction for the intervention strategies offered to patients and patient-colonoscopist perception on colonoscopic perforation. A modified Korean version of the "Second Victim Experience and Support Tool (K-SVEST)" was used to assess the second victim experiences and supportive resources for the colonoscopists.

RESULTS

Survey results from 160 colonoscopists and 165 patients were analyzed. The colonoscopists' satisfaction scores were higher for strategies related to sufficient explanation, empathy, courteous listening, and monetary compensation. The scores of the K-SVEST for the second victim experience were highest in psychological distress, followed by loss of professional self-efficacy, colleague support, physical distress, non-work-related support, institutional support, and turnover intentions/absenteeism. Significant patient-colonoscopist discordance was noted for the same colonoscopic perforation scenario on the judgment of medical error, health professionals' apology, monetary compensation, and criminal penalties for the colonoscopists.

CONCLUSIONS

Colonoscopists can suffer emotionally and physically from the second victim experience after colonoscopic perforation. In addition, the significant patient-colonoscopist discordance should be considered to make a better communication for the colonoscopic perforation.

Education program on medical error disclosure for emergency medicine residents using standardized patients

PURPOSE

We aimed to develop a program for error disclosure for emergency medicine (EM) residents to determine its effects.

METHODS

Fifteen EM residents participated in 2020. The program included two-error disclosure sessions using standardized patients (SPs), a didactic lecture, and debriefing. The Kirkpatrick model was used to evaluate this program. Satisfaction scores and narrative reactions were collected (level 1). Residents were asked to choose their actions and explain reasons for the representative error cases before and after the program (level 2). After 2 months, they were asked to write their experiences of disclosing errors to real patients (level 3). The differences in the disclosing communication scores allocated by the SPs were compared between the senior and junior residents.

RESULTS

The residents' satisfaction scores were high. Before the program, some residents chose not to disclose errors when there were no harmful sequelae at the time of the incident. After the program, opinions changed, and the residents thought that all errors should be disclosed. Before the program, most residents disclosed the errors to patients first; after the program, they would report to the hospital first to receive guidance. After 2 months, five residents reported disclosing errors to real patients. The senior residents' total scores and the scores for "prevention of future errors" were higher.

CONCLUSION

The residents showed confidence in error disclosure while maintaining rapport with the real patient, and some were satisfied with their disclosure approach. Our error disclosure program for EM residents had a positive effect on their behavior and attitude toward error disclosure.

How defensive medicine is defined in European medical literature: a systematic review

OBJECTIVES

Defensive medicine has originally been defined as motivated by fear of malpractice litigation. However, the term is frequently used in Europe where most countries have a no-fault malpractice system. The objectives of this systematic review were to explore the definition of the term 'defensive medicine' in European original medical literature and to identify the motives stated therein.

DESIGN

Systematic review.

DATA SOURCES

PubMed, Embase and Cochrane, 3 February 2020, with an updated search on 6 March 2021.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we reviewed all European original peer-reviewed studies fully or partially investigating 'defensive medicine'.

RESULTS

We identified a total of 50 studies. First, we divided these into two categories: the first category consisting of studies defining defensive medicine by using a narrow definition and the second category comprising studies in which defensive medicine was defined using a broad definition. In 23 of the studies(46%), defensive medicine was defined narrowly as: health professionals' deviation from sound medical practice motivated by a wish to reduce exposure to malpractice litigation. In 27 studies (54%), a broad definition was applied adding … or other self-protective motives. These self-protective motives, different from fear of malpractice litigation, were grouped into four categories: fear of patient dissatisfaction, fear of overlooking a severe diagnosis, fear of negative publicity and unconscious defensive medicine. Studies applying the narrow and broad definitions of defensive medicine did not differ regarding publication year, country, medical specialty, research quality or number of citations.

CONCLUSIONS

In European research, the narrow definition of defensive medicine as exclusively motivated by fear of litigation is often broadened to include other self-protective motives. In order to compare results pertaining to defensive medicine across countries, future studies are recommended to specify whether they are using the narrow or broad definition of defensive medicine.

PROSPERO REGISTRATION NUMBER

CRD42020167215.

The Personal and Professional Impact of Patients' Complaints on Doctors-A Qualitative Approach

Background: Complaints regarding medical practice represent a harsh reality of the current world. Patients have the right to receive explanations and compensation when they are injured during the medical act, but the increased potential for exposure to complaints determines personal and professional consequences for the doctors, with significant impact on their health and practice. Thus, the aim of our research was to analyze in depth the impact of complaints on the doctors involved. Materials and methods: The authors conducted a qualitative study, using a semi-structured interview, addressed to doctors who had complaints from patients. The participants in our research were identified using an adapted version of the snowball method. Results: After the analysis of the interviews using the inductive method, nine themes resulted, seven of which are addressed in this paper: injustice, personal impact, professional impact, difficulties, supportive factors, the attitude of the hospital management and the attitude of colleagues. At the personal level, the doctors were overwhelmed by insomnia, nightmares, stress and anxiety, and at the professional level by doubts about medical decisions, fear, anxiety and the tendency to avoid patients with severe diseases. Conclusions: The study revealed that physicians who had complaints from patients are deeply affected by the complaint itself and the associated investigation procedure, even if, to a lesser extent, some of the participants found motivation for a better management of the situation. The study also showed the need for changes in the legal and medical systems in order to create mechanisms to support the doctors during the investigation process.

Analysis of in court malpractice litigation following pancreatic surgery

BACKGROUND

Pancreatic operations are technically complex with a significant risk of morbidity and mortality. Analysis of litigation following surgery can disclose avoidable errors.

METHODS

Two legal databases, Westlaw and Lexis Nexis, were queried for jury verdicts, settlements and appeal cases in the United States related to pancreatic surgery and malpractice between 1980 and 2020.

RESULTS

Thirty-four cases were analyzed. Pancreaticoduodenectomy (n = 22, 65%) was the most common procedure litigated. Claims most commonly involved malpractice in the postoperative (n = 16) setting. The most common claims were failure to diagnose or treat postoperative complications (n = 16), lack of informed consent (n = 9), and wrongful indication for surgery (n = 8). Seven cases involved incorrect diagnosis of pancreatic cancer. Attending surgeons were the main provider named in the medical malpractice claim in 25 (74%) of the cases. Resident surgeons were named in 5 cases (15%). Half of the cases (n = 17) involved patient deaths. The court ruled in favor of the defendant in 75% of the cases, and the plaintiff in 12.5%. Median payout for settlements and plaintiff verdicts was 783,304 USD (interquartile range (IQR) 1,034,046). Mean time from incident to final disposition was 6.4 years (±3.3).

CONCLUSIONS

Obtaining an accurate preoperative diagnosis may decrease malpractice litigation following pancreatic surgery. By raising awareness to unsafe practices and identifying vulnerable periods of care, these data may serve to enhance provider performance as well as improve patient safety.

Retrospective analysis of medical malpractice claims in tertiary hospitals of China: the view from patient safety

OBJECTIVES

The study analysed medical malpractice claims to assess patient safety in hospitals. The information derived from malpractice claims reflects potential risks and could help lead to reducing medical errors and improving patient safety.

DESIGN, SETTING

We analysed 4380 medical malpractice claims from 351 grade-A tertiary hospitals in China for 2008-2017. We examined the characteristics of medical errors and patient safety, including the types of medical errors, proportionate liabilities and payments for medical malpractice in different clinical specialties.

MAIN OUTCOME MEASURES

We assessed claim characteristics, payment amounts and liability.

RESULTS

Our data analysis demonstrated that 72.5% of the claims involved medical errors, with average payments of US$31 430. The hospital's errors in medical malpractice resulted in 41.4% average liability in patient injury payments. Most medical malpractice cases occurred in Shanghai (817 claims, 18.7%) and Beijing (468 claims, 10.7%). The highest risks for medical error and malpractice claims were related to orthopaedics (11.3% of all claims, 72.8% with medical errors) and obstetrics and gynaecology (10.0% of all claims, 76.0% with medical errors). The highest rates related to proportionate liabilities were observed in otolaryngology (51.9%) and endocrinology (47.7%). Respiratory medicine had the highest proportion of claims in death rates (77.3%). Medical technology errors accounted for 91.8% of the claims and medical ethics errors for 5.8%. The highest average payment was found in cardiovascular surgery (US$41 733) and the lowest in stomatology (US$8822).

CONCLUSIONS

A previous study found that grade-A tertiary hospitals in China have similar medical error rates to general Chinese hospitals. ³⁶Different specialties had different risk characteristics regarding medical errors, payments and proportionate liabilities. Orthopaedics had the highest number of malpractices claims and higher proportionate liability but lower death rates.

Nurses' Experiences with Disclosure of Patient Safety Incidents: A Qualitative Study

Background

Patient safety incidents trigger conflict between healthcare providers and patients. Patients and families want to hear detailed explanations and apologies from medical staff, but nurses may face difficulties with disclosure of patient safety incidents.

Purpose

To identify nurses’ experiences with disclosure of patient safety incidents.

Methods

Data were collected through in-depth interviews with nine clinical and five head nurses and were analyzed using Colaizzi’s phenomenological method.

Findings

After formulating 18 themes representing nurses’ experiences with disclosure of patient safety incidents, we clustered them into four theme clusters: “mixed responses from patients and families,” “caught in a swirl of negative emotions,” “facing the reality that hinders disclosure,” and “waiting for a breakthrough that would enable disclosure”.

Conclusion

Policies, systems, and culture that help both patients and healthcare professionals should be developed.

Reasons for and Facilitating Factors of Medical Malpractice Complaints. What Can Be Done to Prevent Them?

Background and objectives. Medical malpractice is an increasing phenomenon all over the world, and Romania is not spared. This matter is of concern as it has a significant impact on the physicians and the patients involved, as well as on the health care system and society in general. The purpose of our study was to perform an insight analysis on the reasons for medical malpractice complaints as well as the factors that facilitate the complaints to identify specific ways to prevent them and, implicitly, to improve the medical practice. Materials and Methods. The authors conducted a retrospective study of the medical malpractice complaints registered in the period 2006–2019 at the Commission for monitoring and professional competence for malpractice cases in the region of Moldova, Romania, collecting data on both the patients and the medical professionals involved. Results. The authors analyzed 153 complaints directed against 205 medical professionals and identified 15 categories of reasons for complaints, the most significant being related to the occurrence of complications, and to the doctor–patient interaction (e.g., communication, behavior, informed consent). The most frequently reported medical specialties were obstetrics and gynecology, emergency medicine, general surgery, and orthopedics and traumatology. Emergency medicine was often involved in complaints suggesting an over utilization of this department in our country and the need for health policies, which could divert the large number of patients accessing emergency medicine towards primary care. Conclusions. Regarding the dysfunctions in the doctor–patient relationship frequently claimed by patients, the authors concluded that doctors need special undergraduate training and periodic updating during their practice for them to be able to adequately address the challenges of interacting with their patients.

Measuring patient safety culture in maternal and child health institutions in China: a qualitative study

INTRODUCTION

Patient safety culture (PSC) plays a critical role in ensuring safe and quality care. Extensive PSC studies have been undertaken in hospitals. However, little is known about PSC in maternal and child health (MCH) institutions in China, which provide both population-based preventive services as well as individual care for patients.

OBJECTIVES

This study aimed to develop a theoretical framework for conceptualising PSC in MCH institutions in China.

METHODS

The study was undertaken in six MCH institutions (three in Hebei and three in Beijing). Participants (n=118) were recruited through stratified purposive sampling: 20 managers/administrators, 59 care providers and 39 patients. In-depth interviews were conducted with the participants. The interview data were coded using both inductive (based on the existing PSC theory developed by the Agency for Healthcare Research and Quality) and deductive (open coding arising from data) approaches. A PSC framework was formulated through axial coding that connected initial codes and selective coding that extracted a small number of themes.

RESULTS

The interviewees considered patient safety in relation to six aspects: safety and security in public spaces, safety of medical services, privacy and information security, financial security, psychological safety and gap in services. A 12-dimensional PSC framework was developed, containing 69 items. While the existing PSC theory was confirmed by this study, some new themes emerged from the data. Patients expressed particular concerns about psychological safety and financial security. Defensive medical practices emerged as a PSC dimension that is associated with not only medical safety but also financial security and psychological safety. Patient engagement was also valued by the interviewees, especially the patients, as part of PSC.

CONCLUSIONS

Although there are some common features in PSC across different healthcare delivery systems, PSC can also be context specific. In MCH settings in China, the meaning of 'patient safety' goes beyond the traditional definition of patients. General well-being, health and disease prevention are important anchor points for defining PSC in such settings.

Frequency, Expected Effects, Obstacles, and Facilitators of Disclosure of Patient Safety Incidents: A Systematic Review

Objectives

We performed a systematic review to assess and aggregate the available evidence on the frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents (DPSI).

Methods

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for this systematic review and searched PubMed, Scopus, and the Cochrane Library for English articles published between 1990 and 2014. Two authors independently conducted the title screening and abstract review. Ninety-nine articles were selected for full-text reviews. One author extracted the data and another verified them.

Results

There was considerable variation in the reported frequency of DPSI among medical professionals. The main expected effects of DPSI were decreased intention of the general public to file medical lawsuits and punish medical professionals, increased credibility of medical professionals, increased intention of patients to revisit and recommend physicians or hospitals, higher ratings of quality of care, and alleviation of feelings of guilt among medical professionals. The obstacles to DPSI were fear of medical lawsuits and punishment, fear of a damaged professional reputation among colleagues and patients, diminished patient trust, the complexity of the situation, and the absence of a patient safety culture. However, the factors facilitating DPSI included the creation of a safe environment for reporting patient safety incidents, as well as guidelines and education for DPSI.

Conclusions

The reported frequency of the experience of the general public with DPSI was somewhat lower than the reported frequency of DPSI among medical professionals. Although we identified various expected effects of DPSI, more empirical evidence from real cases is required.

Perceptions of the general public and physicians regarding open disclosure in Korea: a qualitative study

BACKGROUND

Experience with open disclosure and its study are restricted to certain western countries. In addition, there are concerns that open disclosure may be less suitable in non-western countries. The present study explored and compared the in-depth perceptions of the general public and physicians regarding open disclosure in Korea.

METHODS

We applied the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist to this qualitative study. We conducted 20 in-depth interviews and four focus group discussions with 16 physicians and 18 members of the general public. In-depth interviews and focus group discussions were performed according to semi-structured guidelines developed according to a systematic review of open disclosure. We conducted a directed content analysis by analyzing the verbatim transcripts and field notes in accordance with the predetermined guidelines.

RESULTS

Open disclosure perceptions were summarized in terms of the "five Ws and one H" (who, what, where, when, why, and how). All physician and general public participants acknowledged the normative justifiability of open disclosure. The participants mostly agreed on the known effects of open disclosure, but the physicians had negative opinions on its expected effects, such as decreased intention of the general public to file lawsuits and increased credibility of medical professionals. Generally, the participants thought that open disclosure is required for medical errors causing major harm. However, the physicians and general public had conflicting opinions on the need for open disclosure of near misses. Most physicians did not know how to conduct open disclosure and some physicians had bad experiences due to inappropriate or incomplete open disclosure.

CONCLUSION

Physicians and the general public in Korea acknowledge the need for open disclosure. Guidelines according to the type of patient safety incident are required to encourage physicians to more readily conduct open disclosure. Furthermore, hospitals need to consider organizing a dedicated team and hiring experts for open disclosure.

Third Year Medical School Students' Experiences of Revealing Patients' Stories through Role Playing

OBJECTIVE

Studying medicine is hard and it takes longer time compared to other majors. In addition, medical students find medical education boring. It is now necessary to turn medical education into an enjoyable and interesting way. The aim of this study is to evaluate the impact of an educational program related to how to learn taking medical history and how an effective patient-doctor interview should be. The program is structured in various scenarios, on the students learning skills, by the "role playing" method.

MATERIALS AND METHODS

A scenario prepared by the lecturer was employed in this study. While one of the students acted in a doctor role, the other one played in the role of patient's relative. The lecturer always played in the role of patient. After performing the role playing, students' written and oral feedbacks were gathered. Data were analysed by using SPSS 20.0 program.

RESULTS

A total of 470 feedbacks (51.3% were given by the female students) were taken from the students. Thirty-three volunteer students, nineteen of them were male, took part in the role playing. In the patient-doctor interview, the field that students were best were greeting the patients and dealing only with patients during the examination. The mean scores were 3.81±0.95 and 3.79±0.94 respectively. The ability to "summarize" and to "address the patient with his/her name" had the lowest scores; the mean scores of the students in these areas were 2.94±1.11 and 2.70±1.31, respectively.

CONCLUSION

Medical education is a long and tough process. Therefore, it should be interesting, attention getting and cheerful. Role playing can be effective in meeting that need.

Explaining the unexplainable - the impact of physicians' attitude towards litigation on their incident disclosure behaviour

RATIONALE, AIMS AND OBJECTIVES

This study aims to provide in-depth insight into the emotions and thoughts of physicians towards malpractice litigation, and how these relate to their incident disclosure behaviour.

METHODS

Thirty-one Dutch physicians were interviewed and completed short questionnaires regarding malpractice litigation. We used hierarchical cluster analysis to identify physician clusters. Additional qualitative data were analysed.

RESULTS

Physicians vary largely in their attitude towards malpractice litigation, and their attitude is not straightforward related to their disclosure behaviour. Based on their responses physicians could be divided into two clusters: one with a positive and one with a negative attitude. Physicians with a negative attitude showed often, but also 6 out of 15 not, a reluctance to disclose, whereas the majority in the positive attitude cluster (12 out of 16) showed no reluctance. If, what and how physicians disclose incidents depends on a complex interplay of their emotions and thoughts regarding litigation, and not only on their fear of litigation as many studies assume.

CONCLUSIONS

Due to the variation among physicians in their litigation attitude and behaviour in terms of incident disclosure the oft-heard call for 'openness' about medical incidents will not be easy to achieve. A coaching system in which physicians can share and discuss their differing attitudes and disclosure principles, teaching medical students and junior physicians about disclosure, and explaining how to organize emotional and legal support for oneself in case of litigation could decrease stress feelings and support open disclosure behaviour.