Association between physician explanatory behaviors and substandard care in adjudicated cases in Japan

Dentists' Legal Liability and Duty of Explanation in Dental Malpractice Litigation in Japan

Introduction

Dental litigation accounts for approximately 10% of medical cases in Japan. This study sought to identify factors related to dentists’ legal liability in Japan, including their duty to explain procedures and treatments to their patients.

Methods

We analysed court decisions in 166 dental malpractice cases litigated in Japan between 1978 and 2017. To identify factors related to the legal liability of dentists, an analysis was performed to evaluate the associations among patient characteristics, dentist characteristics, litigation, and dentists’ explanatory behaviour.

Results

Of the 36 cases related to dentist liability, the study identified 23 cases (63.9%) of litigation in which the dentists were found to be in violation of their duty to provide an explanation. Regarding the severity of injury, the ratio of death and permanent disability was significantly higher in decisions in which the purpose of the explanation was something other than obtaining the patient's consent compared with decisions to obtain the patient's consent (P = .014).

Conclusions

In cases in which the dentist was found legally responsible, the proportion of cases involving procedural negligence with the explanation of medical guidance was significantly higher. Dentists should pay careful attention not only to the patient's consent but also to their explanations, including “medical guidance.” Moreover, they should recognise that inappropriate explanations correlate with serious errors.

Team Approach: Safety and Value in the Practice of Complex Adult Spinal Surgery

Surgical management of complex adult spinal deformities is of high risk, with a substantial risk of operative mortality. Current evidence shows that potential risk and morbidity resulting from surgery for complex spinal deformity may be minimized through risk-factor optimization. The multidisciplinary team care model includes neurosurgeons, orthopaedic surgeons, physiatrists, anesthesiologists, hospitalists, psychologists, physical therapists, specialized physician assistants, and nurses. The multidisciplinary care model mimics previously described integrated care pathways designed to offer a structured means of providing a comprehensive preoperative medical evaluation and evidence-based multimodal perioperative care. The role of each team member is illustrated in the case of a 66-year-old male patient with previous incomplete spinal cord injury, now presenting with Charcot spinal arthropathy and progressive vertebral-body destruction resulting in lumbar kyphosis.

A comparison of medical litigation filed against obstetrics and gynecology, internal medicine, and surgery departments

Background

The aim of this study was to review the typical factors related to physician’s liability in obstetrics and gynecology departments, as compared to those in internal medicine and surgery, regarding a breach of the duty to explain.

Methods

This study involved analyzing 366 medical litigation case reports from 1990 through 2008 where the duty to explain was disputed. We examined relationships between patients, physicians, variables related to physician’s explanations, and physician’s breach of the duty to explain by comparing mean values and percentages in obstetrics and gynecology, internal medicine, and surgical departments with the t-test and χ² test.

Results

When we compared the reasons for decisions in cases where the patient won, we found that the percentage of cases in which the patient’s claim was recognized was the highest for both physician negligence, including errors of judgment and procedural mistakes, and breach of the duty to explain, in obstetrics and gynecology departments; breach of the duty to explain alone in internal medicine departments; and mistakes in medical procedures alone in surgical departments (p = 0.008). When comparing patients, the rate of death was significantly higher than that of other outcomes in precedents where a breach of the duty to explain was acknowledged (p = 0.046). The proportion of cases involving obstetrics and gynecology departments, in which care was claimed to be substandard at the time of treatment, and that were not argued as breach of a duty to explain, was significantly higher than those of other evaluated departments (p <0.001). However, internal medicine and surgical departments were very similar in this context. In obstetrics and gynecology departments, the proportion of cases in which it had been conceded that the duty to explain had been breached when seeking patient approval (or not) was significantly higher than in other departments (p = 0.002).

Conclusion

It is important for physicians working in obstetrics and gynecology departments to carefully explain the risk of death associated with any planned procedure, and to obtain genuinely informed patient consent.

Adult Spinal Deformity Patients Recall Fewer Than 50% of the Risks Discussed in the Informed Consent Process Preoperatively and the Recall Rate Worsens Significantly in the Postoperative Period

STUDY DESIGN

Recall of the informed consent process in patients undergoing adult spinal deformity surgery and their family members was investigated prospectively.

OBJECTIVE

To quantify the percentage recall of the most common complications discussed during the informed consent process in adult spinal deformity surgery, assess for differences between patients and family members, and correlate with mental status.

SUMMARY OF BACKGROUND DATA

Given high rates of complications in adult spinal deformity surgery, it is critical to shared decision making that patients are adequately informed about risks and are able to recall preoperative discussion of possible complications to mitigate medical legal risk.

METHODS

Patients undergoing adult spinal deformity surgery underwent an augmented informed consent process involving both verbal and video explanations. Recall of the 11 most common complications was scored. Mental status was assessed with the mini-mental status examination-brief version. Patients subjectively scored the informed consent process and video. After surgery, the recall test and mini-mental status examination-brief version were readministered at 5 additional time points: hospital discharge, 6 to 8 weeks, 3 months, 6 months, and 1 year postoperatively. Family members were assessed at the first 3 time points for comparison.

RESULTS

Fifty-six patients enrolled. Despite ranking the consent process as important (median overall score: 10/10; video score: 9/10), median patient recall was only 45% immediately after discussion and video re-enforcement and subsequently declined to 18% at 6 to 8 weeks and 1 year postoperatively. Median family recall trended higher at 55% immediately and 36% at 6 to 8 weeks postoperatively. The perception of the severity of complications significantly differs between patient and surgeon. Mental status scores showed a transient, significant decrease from preoperation to discharge but were significantly higher at 1 year.

CONCLUSION

Despite being well-informed in an optimized informed consent process, patients cannot recall most surgical risks discussed and recall declines over time. Significant progress remains to improve informed consent retention.

LEVEL OF EVIDENCE

3.

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.

Safe practice of cosmetic dermatology: avoiding legal tangles

The present day dermatologists, in addition to conventional skin physicians, are also dermatologic-surgeons and cosmetologists in their practice. The cosmetic procedures have the inherent risk of malpractice litigations leaving an unsatisfied patient and a troublesome lawsuit against the doctor. A MEDLINE search was conducted for article with words such as legal issues and dermatology, malpractice in dermatology, safe practice of cosmetology etc. The selected articles are scrutinized and compiled so as to help the young dermatologists to have a comprehensive overview of safe cosmetology practice. This article aims at sensitizing the young dermatologists for the possible complications and provides an overview of safe practice. It also provides a list of simple routine precautions which helps the dermatologist to avoid unnecessary trips to the courthouse.