The right to be informed and fear of disclosure: sustainability of a full error disclosure policy at an Italian cancer centre/clinic

Analysis of Medico-Legal Complaint Data: A Retrospective Study of Three Large Italian University Hospitals

(1) Background: Identifying hospital-related critical, and excellent, areas represents the main goal of this paper, in both a national and local setting. Information was collected and organized for an internal company's reports, regarding civil litigation that has been affecting the hospital, to relate the obtained results with the phenomenon of medical malpractice on a national scale. This is for the development of targeted improvement strategies, and for investing available resources in a proficient way. (2) Methods: In the present study, data from claims management in Umberto I General Hospital, Agostino Gemelli University Hospital Foundation and Campus Bio-Medico University Hospital Foundation, from 2013 to 2020 were collected. A total of 2098 files were examined, and a set of 13 outcome indicators in the assessment of "quality of care" was proposed. (3) Results: From the total number, only 779 records (37.1%) were attributable to the categories indexable for the present analysis. This data highlights how, following a correct and rigorous categorization of hospital events, it is possible to analyze these medico-legal aspects using a small number of indicators. Furthermore, it is important to consider how a consistent percentage of remaining events was difficult to index, and was also of poor scientific interest. (4) Conclusions: The proposed indicators do not require standards to be compared to, but provide a useful instrument for comparative purposes. In fact, in addition to comparative assessment between different business realities distributed throughout the territory, the use of outcome indicators allows for a longitudinal analysis evaluating the performance of an individual structure over time.

Medical error disclosure in the Italian healthcare context: A delicate balance between ethical obligations and the principle of non-self-incrimination

Surprisingly, Italian legal doctrine and jurisprudence never systematically address the medical error disclosure issue. The topic of medical error communication represents a non-negligible profile of interest, relating to the possible detrimental effects on doctors who accuse themselves of conduct that does not comply with the lex artis. The effects of error disclosure on the effectiveness of insurance guarantees in civil and administrative liability are particularly relevant, as are the implications for ethical liability. Although the burden of reporting an error falls within the wide range of informative duties doctors hold, it still seems far from having found a factual statement in clinical practice, especially in Italy. This applies whether the error has a marginal or significant impact on the patient's health. The reasons lay in a very contradictory legal framework. Doctors tend with increasing ease not to comply with their information obligation - especially in cases where fulfilling this duty means admitting a personal, professional error - to preserve the integrity of their professional images. This article aims to offer a brief overview of that topic in the context of Italian healthcare.

Analysis of Inadequacies in Hospital Care through Medical Liability Litigation

Over the past two decades, health litigation has followed an exponentially incremental trend. As insurance companies tend to limit their interest because of the high risk of loss, health facilities increasingly need to internalize dispute management. This study was conducted through a retrospective analysis of existing files concerning the civil litigation of the Sant’Andrea Hospital in Rome. All claims from 1 June 2010 to 30 June 2019 were included. Paid claims were further classified according to the areas of health care inappropriateness found. Authors indexed 567 different claims along the study period, with an average number of 59 per year (range 38–77). The total litigation involved 47 different units; more than 40% concerned 5 high-incidence wards or services. Concerning the course of disputes, 91 cases were liquidated before a judicial procedure was instituted, while 177 cases landed in a civil court. Globally, 131 different claims hesitated in compensation, for a total of 16 million 625 thousand euros, 41% of which was related to the internal medicine area. Dealing with the inappropriateness analysis, clinical performance alone involved 76 cases, for a total of 10 million 320 thousand euros, while organization defects involved 20 disputes equivalent to 1 million 788 thousand euros. The aim of this study was to enhance the clinical risk management at our facility through a litigation analysis.

The Motion of the Italian National Bioethics Committee on Aggressive Treatment towards Children with Limited Life Expectancy

The motion of the Italian National Bioethics Committee entitled "Aggressive treatment or therapeutic obstinacy on young children with limited life expectancy" comprises a premise that rejects therapeutic obstinacy and makes 12 recommendations. Recommendation no. 1 states the general rules: it ascribes a cardinal role to a shared care plan, it supports pain management therapy and pain relief, it opposes ineffective and disproportionate clinical treatment and defensive medicine. The other recommendations are correlated to the enacting of a national law establishing clinical ethics committees in paediatric hospitals; participation of parents and their fiduciaries in the decision-making processes; recourse to courts only as extrema ratio in the event of irremediable disagreement between the medical team and the family members; accompaniment at the end of life also through continuous deep sedation combined with pain therapy; access to palliative care; the need to reinforce research on pain and suffering in children; clinical trials and research studies conducted in children; the training of doctors, healthcare personnel and psychologists, to support parents in emotional and practical terms; the facilitation of the closeness of parents to children in extremely precarious clinical conditions; the relevant role of the associations of parents of sick children. Comments are made, in particular, about the innovative recommendations respectively relating to the adoption of care planning, the establishment, by law, of clinical ethics committees in paediatric hospitals and the limitation of recourse to courts-only as extrema ratio-in the event of irremediable disagreement between the medical team and the family members.

Risk Management in the New Frontier of Professional Liability for Nosocomial Infection: Review of the Literature on Mycobacterium Chimaera

Background: Mycobacterium chimaera (MC) is of recent origin and belongs to the large family of non-tuberculous mycobacteria. In recent years, it has shown a high infectious capacity via the aerosol produced by operating room equipment, such as heater–cooler units (HCU). The infection has a long latent period and high mortality rate. Genetic and epidemiological studies have shown that there is a clear link between the infection and a specific HCU model manufactured by LivaNova/Sorin. There is, therefore, a strong possibility that contamination occurs during device construction. The objective of this article is to describe the characteristics of this particular infection in view of the medico–legal implications on professional liability, specifically focusing on current evidence regarding contamination prevention. Methods: we have analyzed the clinical characteristics and data from the autopsic investigations performed on a patient who died as a result of MC infection, in addition to analyzing all pertinent recommendation documents available internationally. We searched for all articles in the literature available on MEDLINE between 1995 and 30 July 2020, using the search words “Mycobacterium chimaera”. We then analyzed those articles and reported only those that provide useful information regarding prevention techniques for containing dissemination and contamination. Results: the literature review produced 169 results that highlight the need to develop systems to mitigate and eliminate the risk of MC infection in operating rooms such as physical containment measures, e.g. device replacement, use of safe water, providing patients with information, and training healthcare professionals. Conclusions: from a medico–legal viewpoint, this particular situation represents a new frontier of professional liability, which includes manufacturers of electromedical equipment. In order to comprehend the true extent of this silent global epidemic, the development of an organic, preventative monitoring system is essential.

Disclosure of medical errors: physicians' knowledge, attitudes and practices (KAP) in an oncology center

Background

Between the need for transparency in healthcare, widely promoted by patient’s safety campaigns, and the fear of negative consequences and malpractice threats, physicians face challenging decisions on whether or not disclosing medical errors to patients and families is a valid option.

We aim to assess the knowledge, attitudes and practices (KAP) of physicians in our center regarding medical error disclosure.

Methods

This is a cross-sectional self-administered questionnaire study. The questionnaire was piloted and no major modifications were made.

A day-long training workshop consisting of didactic lectures, short and long case scenarios with role playing and feedback from the instructors, were conducted. Physicians who attended these training workshops were invited to complete the questionnaire at the end of the training, and physicians who did not attend any training were sent a copy of the questionnaire to their offices to complete. To assure anonymity and transparency of responses, we did not query names or departments.

Descriptive statistics were used to present demographics and KAP. The differences between response\s of physicians who received the training and those who did not were analyzed with t-test and descriptive statistics. The 0.05 level of significance was used as a cutoff measure for statistical significance.

Results

Eighty-eight physicians completed the questionnaire (55 attended training (62.50%), and 33 did not (37.50%)). Sixty Five percent of physicians were males and the mean number of years of experience was 16.5 years. Eighty-Seven percent (n = 73) of physicians were more likely to report major harm, compared to minor harm or no harm. Physicians who attended the workshop were more knowledgeable of articles of Jordan’s Law on Medical and Health Liability (66.7% vs 45.5%, p-value = 0.017) and the Law was more likely to affect their decision on error disclosure (61.8% vs 36.4%, p-value = 0.024).

Conclusion

Formal training workshops on disclosing medical errors have the power to positively influence physicians’ KAP toward disclosing medical errors to patients and possibly promoting a culture of transparency in the health care system.

New Rules on Patient's Safety and Professional Liability for the Italian Health Service

BACKGROUND

The phenomenon of clinical negligence claims has rapidly spread to United States, Canada and Europe assuming the dimensions and the severity of a pandemia. Consequently, the issues related to medical malpractice need to be studied from a transnational perspective since they raise similar problems in different legal systems.

METHODS

Over the last two decades, medical liability has become a prominent issue in healthcare policy and a major concern for healthcare economics in Italy. The failures of the liability system and the high cost of healthcare have led to considerable legislative activity concerning medical malpractice liability, and a law was enacted in 2012 (Law no. 189/2012), known as the "Balduzzi Law".

RESULTS

The law tackles the mounting concern over litigation related to medical malpractice and calls for Italian physicians to follow guidelines. Briefly, the law provided for the decriminalisation of simple negligence of a physician on condition that he/she followed the guidelines and "good medical practice" while carrying out his/her duties, whilst the obligation for compensation, as defined by the Italian Civil Code, remained. Judges had to consider that the physician followed the provisions of the guidelines but nevertheless caused injury to the patient.

CONCLUSION

However, since the emission of the law, thorny questions remain which have attracted renewed interest and criticism both in the Italian courts and legal literature. Since then, several bills have been presented on the topic and these have been merged into a single text entitled "Regulations for healthcare and patient safety and for the professional responsibility of healthcare providers".

The contribution of legal medicine in clinical risk management

Background

In advanced health services, a main objective is to promote the culture of safety and clinical risk management. In this regard, the reporting of sentinel events fits within a perspective of error analysis, attempting to propose solutions aimed at preventing a new occurrence of the harmful event. The purpose of this study is to analyze the contribution of medico-legal litigation in the management of clinical risk and to propose an organizational model so as to coordinate the intervention of clinical risk management and medico-legal services.

Methods

Retrospective review of 206 cases of medico-legal litigation, settled against a Hospital of a North-eastern city in Italy from January 1, 2014 and December 31, 2015.

Results

Approximately 20% of cases, that are classifiable as “sentinel events”, were not reported due to various factors. The reason that these events are under-reported is mainly due to the latency between the event itself and its manifestation as a serious damage to health as well as the discomfort in reporting the events of this kind, which is still widespread among healthcare workers.

The systematic research of the available documentation for medico-legal purposes permits the acquisition of more information concerning the clinical event, thereby increasing the number and accuracy of the reports to the clinical risk unit.

Conclusion

The analysis of medico-legal litigation is a valid tool to enhance the reporting of “sentinel events”. One possible proposal is the implementation of an organizational model to establish a rapid procedure for the reporting of sentinel events during the evaluation of medico-legal litigations.

Primary care physicians and oncologists are partners in cancer announcement

PURPOSE

The primary care physician (PCP) is central to cancer patients' management. Announcement of the diagnosis is a critical time for patients, even if they wish to be fully informed. The French National Cancer Plan, developed 10 years ago, includes a diagnosis disclosure procedure (DDP) to be used by oncologists, which makes specific provision for a time of communication with PCPs. So, we asked PCPs about their role in cancer announcement since the launching of the DDP.

METHODS

A cross-sectional prospective study by postal questionnaire was sent to 500 PCPs in the largest region of France. It addressed (1) the characteristics of cancer disclosure, (2) PCPs' source of information of the diagnosis, (3) time of disclosure, (4) information exchange, and (5) the physicians' knowledge of the DDP.

RESULTS

The response rate was 48 %. In 20 % of cases, oncologists delegated the announcement to PCPs. In 19 % of cases, it was the patient or their family who informed the PCP of the diagnosis. We identified three announcement phases of cancer diagnosis in the physicians' clinical practice: pre-disclosure, disclosure, and repeat disclosure. In 57 % of cases, PCPs lacked information on prognosis and in 60 % on treatment. Regarding the DDP, nearly half of PCPs did not know the procedure itself or its content.

CONCLUSION

PCPs announce the cancer diagnosis, even if they have not received the necessary information to do so. The DDP needs to be adapted for use in primary care practice.

Errors and malpractice lawsuits in radiology: what the radiologist needs to know

All medical specialties dealing with patients include an intrinsic risk in exposing them to issues resulting from human errors. Radiology is not spared from this risk since it includes "decision-making under conditions of uncertainty." In medical imaging, the line between the word "error" and misdiagnosis or discrepancy is very difficult to demarcate, mainly because the diagnostic process is not a binary relation and it is not always possible to establish if a pathological condition is present or not. The error in radiology is strongly related to the diagnostic process; hence, it can be defined as a "diagnostic error" which represents the most common cause of medical malpractice suits against radiologists. In this paper, the authors described the features of errors occurring in radiology, trying to establish their impact and prevalence. Secondly, some data coming from different countries were compared in order to highlight the most frequent causes leading to malpractice lawsuits in radiology and how the phenomenon of malpractice in this field is represented worldwide.