Improved hospital safety performance and reduced medicolegal risk: an ecological study using 2 Canadian databases

Medico-legal risk and use of medical directives in the emergency department

PURPOSE

The medico-legal risk associated with application of medical directives in the emergency department (ED) is unknown. The objective of this study was to describe and analyze factors associated with medico-legal risk in cases involving medical directives in the ED.

METHODS

We conducted a descriptive analysis of closed medico-legal cases [hospital complaints, regulatory authority (i.e., College) complaints, and civil legal actions] involving emergency physicians in Canadian EDs involving medical directives (alternate terms including "standing order", "nursing initiated", "nurse initiated", "nursing order", "triage initiated", "triage ordered", "directive", "ED protocol", and "ED's protocol"). We used data from closed cases involving the Canadian Medical Protective Association from January 2016 until December 2021. We abstracted descriptive factors of the cases and used a framework for contributing factors classification.

RESULTS

From 2016 until 2021, 43,332 cases were closed and 1957 involved emergency physicians for which there was medico-legal information available for analysis. In all, 28 involved emergency physicians and medical directives. Situational awareness, team communication, and issues with clinical decision-making were the most important factors contributing to harm and medico-legal risk. Peer experts were critical of physicians not reviewing all results available for patients when initiated through a directive, misinterpreting test results, a less than thorough initial assessment, and of failing to reassess patients or re-order investigations when indicated.

CONCLUSION

Our findings suggest that the medico-legal risk exposure from the use of medical directives in the ED is low. Emergency departments may consider implementing systems to support adherence to medical directive policies, ensure physicians are alerted when medical directives are completed in a timely fashion, and leverage tools to notify the healthcare team when results have not been reviewed.

Evaluation of validity and reliability of video analysis and live observations to assess trauma team performance

INTRODUCTION

A trauma resuscitation is dynamic and complex process in which failures could lead to serious adverse events. In several trauma centers, evaluation of trauma resuscitation is part of a hospital's quality assessment program. While video analysis is commonly used, some hospitals use live observations, mainly due to ethical and medicolegal concerns. The aim of this study was to compare the validity and reliability of video analysis and live observations to evaluate trauma resuscitations.

METHODS

In this prospective observational study, validity was assessed by comparing the observed adherence to 28 advanced trauma life support (ATLS) guideline related tasks by video analysis to life observations. Interobserver reliability was assessed by calculating the intra class coefficient of observed ATLS related tasks by live observations and video analysis.

RESULTS

Eleven simulated and thirteen real-life resuscitations were assessed. Overall, the percentage of observed ATLS related tasks performed during simulated resuscitations was 10.4% (P < 0.001) higher when the same resuscitations were analysed using video compared to live observations. During real-life resuscitations, 8.7% (p < 0.001) more ATLS related tasks were observed using video review compared to live observations. In absolute terms, a mean of 2.9 (during simulated resuscitations) respectively 2.5 (during actual resuscitations) ATLS-related tasks per resuscitation were not identified using live observers, that were observed through video analysis. The interobserver variability for observed ATLS related tasks was significantly higher using video analysis compared to live observations for both simulated (video analysis: ICC 0.97; 95% CI 0.97-0.98 vs. live observation: ICC 0.69; 95% CI 0.57-0.78) and real-life witnessed resuscitations (video analyse 0.99; 95% CI 0.99-1.00 vs live observers 0.86; 95% CI 0.83-0.89).

CONCLUSION

Video analysis of trauma resuscitations may be more valid and reliable compared to evaluation by live observers. These outcomes may guide the debate to justify video review instead of live observations.

Patterns and trends among physicians-in-training named in civil legal cases: a retrospective analysis of Canadian Medical Protective Association data from 1993 to 2017

BACKGROUND

Medico-legal data show opportunities to improve safe medical care; little is published on the experience of physicians-in-training with medical malpractice. The purpose of this study was to examine closed civil legal cases involving physicians-in-training over time and provide novel insights on case and physicians characteristics.

METHODS

We conducted a retrospective descriptive study of closed civil legal cases at the Canadian Medical Protective Association (CMPA), a mutual medico-legal defence organization for more than 105 000 physicians, representing an estimated 95% of physicians in Canada. Eligible cases involved at least 1 physician-in-training and were closed between 1993 and 2017 (for time trends) or 2008 and 2017 (for descriptive analyses). We analyzed case rates over time using Poisson regression and the annualized change rate. Descriptive analyses addressed case duration, medico-legal outcome and patient harm. We explored physician specialties and practice characteristics in a subset of cases.

RESULTS

Over a 25-year period (1993-2017), 4921 physicians-in-training were named in 2951 closed civil legal cases, and case rates decreased significantly (β = -0.04, 95% confidence interval -0.05 to -0.03, where β was the 1-year difference in log case rates). The annualized change rate was -1.1% per year. Between 2008 and 2017, 1901 (4.1%) of 45 967 physicians-in-training were named in 1107 civil legal cases. Cases with physicians-in-training generally involved more severe patient harm than cases without physicians-in-training. In a subgroup with available information (n = 951), surgical specialties were named most often (n = 531, 55.8%).

INTERPRETATION

The rate of civil legal cases involving physicians-in-training has diminished over time, but more recent cases featured severe patient harm and death. Efforts to promote patient safety may enhance medical care and reduce the frequency and severity of malpractice issues for physicians-in-training.

Trends and Contributing Factors in Medicolegal Cases Involving Spine Surgery

STUDY DESIGN

Retrospective descriptive study.

OBJECTIVE

The aim of this study was to describe closed medicolegal cases involving physicians and spine surgery in Canada from a trend and patient safety perspective.

SUMMARY OF BACKGROUND DATA

Spine surgery is a source of medicolegal complaints against surgeons partly owing to the potential severity of associated complications. In previous medicolegal studies, researchers applied a medicolegal lens to their analyses without applying a quality improvement or patient safety lens.

METHODS

The study comprised a 15-year medicolegal trend analysis and a 5-year contributing factors analysis of cases (civil legal and regulatory authority matters) from the Canadian Medical Protective Association (CMPA), representing an estimated 95% of physicians in Canada. Included cases were closed by the CMPA between 2004 and 2018 (trends) or 2014 and 2018 (contributing factors). We fit a linear trend line to the annual rates of spine surgery cases per 1000 physician-years of CMPA membership for physicians in a neurosurgery or orthopedic surgery specialty. We then applied an ANOVA type III sum of squares test to determine the statistical significance of the annualized change rate over time. For the contributing factors analysis, we reported descriptive statistics for patient and physician characteristics, patient harm, and peer expert criticisms in each case.

RESULTS

Our trend analysis included 340 cases. Case rates decreased significantly at an annualized change rate of -4.7% (P  = 0.0017). Our contributing factors analysis included 81 civil legal and 19 regulatory authority cases. Most patients experienced health care-related harm (89/100, 89.0%). Peer experts identified intraoperative injuries (29/89, 32.6%), diagnostic errors (14/89, 15.7%), and wrong site surgeries (16/89, 18.0%) as the top patient safety indicators. The top factor contributing to medicolegal risk was physician clinical decision-making.

CONCLUSION AND RELEVANCE

Although case rates decreased, patient harm was attributable to health care in the majority of recently closed cases. Therefore, crucial opportunities remain to enhance patient safety in spine surgery.Level of Evidence: 4.

Re: Canada's System of Liability Coverage in the Event of Medical Harm: Is It Time for No-Fault Reform?

As an active participant in discussing improvements to the canadian medical liability system, the Canadian Medical Protective Association (CMPA) read with interest the article noted. We were surprised that the authors did not undertake a more systematic literature review of the current medical liability system or consider reforms other than the no-fault model. We also noted the significant omission of any discussion regarding the role of hospitals and other healthcare professionals in the medical liability system.

The effectiveness of handout assisted versus verbal consent on post-operative recall and understanding - A randomized control study

BACKGROUND

Consent is an important component of surgical care. Poorly attempted consent bears significant ethical and legal implications. We assessed the effectiveness of handouts in improving postoperative consent understanding and recall compared to standard verbal consent during laparoscopic cholecystectomy as a tool that may improve information retention and leads to better treatment satisfaction.

METHODS

This is a prospective block randomized, non-blinded study conducted at a single tertiary hospital. Patients undergoing elective laparoscopic cholecystectomy between August 2017 and October 2018 were recruited and randomized into Handout Assisted Consent (HC) and Verbal Consent (VC) group. The HC group was given an adjunct handout on laparoscopic cholecystectomy during consent process in addition to the standard verbal consent. A validated open-ended verbal understanding and recall questionnaire was administered to all patients in both groups at Day 1, 30 and 90 after surgery. Patient satisfaction of the consent process was evaluated with Likert scale.

RESULTS

A total of 79 patients were enrolled, 41 patients and 38 patients in VC and HC groups respectively. Level of understanding among patients were equal and consistent across time in both groups (P > 0.05). There was significant decline (P < 0.0001) for both groups in ability to recall information between Day 1 to Day 30 and Day 30 to Day 90. A slightly higher satisfaction rate was found among patients that received HC (P > 0.05).

CONCLUSION

There is good consistent understanding of the surgery in both groups. However, recall of specific surgical consent items decreased significantly over time in both groups. Handouts may have increased satisfaction among patients but did not improve recall in this preliminary study.

TRIAL REGISTRATION

MREC No.:201783-5468.

Factors associated with wide variation in clinical litigation rates across acute NHS trusts in England: a cross-sectional analysis

OBJECTIVE

Identify organizational factors associated with high clinical litigation rates among acute National Health Service (NHS) trusts in England.

DESIGN

Cross-sectional analysis using routine data.

SETTING

NHS trusts in England.

PARTICIPANTS

A total of 235 NHS trusts used the NHS Clinical Negligence Scheme in 2016-17. Ninety-seven trusts (41.3%) with no maternity services, 2 (0.9%) providing specialized services and 3 (1.2%) without clinical negligence claims were excluded. Hence, the remaining 133 trusts (56.6%) were included.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURES

Rate of clinical litigation by trust per 100 000 occupied bed days.

RESULTS

The mean rate of clinical litigation was 25.4 per 100 000 occupied bed days. In univariable analyses, higher values of summary hospital-level mortality indictor, staff sickness, written complaints, patient safety incidents and being in the North of England led to increased clinical litigation rates. Conversely, higher patient admissions, NHS Staff Survey overall engagement score and occupied bed days led to decreased clinical litigation rates. In the multivariable model, factors associated with increased clinical litigation rates were as follows: summary mortality hospital-level indicator (SHMI) (0.9 increase in litigation rate per 0.05 increase in SHMI; P = 0.012); new written complaints (0.62 increase per 50 complaints higher; P < 0.001); located in the North of England compared to London (5.22 higher; P < 0.001). Conversely, a higher number of occupied bed days (-0.64 change per 50 000 days higher; P = 0.007) was associated with lower clinical litigation rates.

CONCLUSIONS

This study identified organizational factors associated with clinical litigation, which will be of interest to clinicians and the NHS. This research also highlights areas for further investigation.

Clinical negligence costs: taking action to safeguard NHS sustainability

The NHS cannot afford to divert more and more money to litigation, and we need to tackle the problem at source. Tim Draycott and colleagues set out four principles to reduce avoidable harm

Implementing Obstetrics Quality Improvement, Driven by Medico-legal Risk, is Associated With Improved Workplace Culture

OBJECTIVE

This study implemented a quality improvement program based on knowledge of medico-legal risk in obstetrics and sought to evaluate the impact of this program on workplace culture.

METHODS

The study conducted needs assessments with front-line providers working in the obstetrical unit of the Queensway Carleton Hospital, an urban community hospital in Ottawa, Ontario, and included the safety, communication, operational reliability, and engagement (SCORE) survey. The study investigators delivered training in quality improvement science and co-developed three projects that were based on their alignment with local needs and aggregate medico-legal risk data: an organized team response to the need for an immediate cesarean section, a protocol for managing patients who present at term with pre-labour rupture of membranes, and regular morning team briefings. Outcome measures were determined for each project from a quality improvement indicator framework, and coaching was provided to project leads. Participants completed the SCORE survey and a program effectiveness tool after the intervention.

RESULTS

The majority of participants (75.2% of 153 pre-intervention and 63.1% of 157 post-intervention participants) completed the SCORE surveys. Post-intervention improvements were found in teamwork, learning environment, and safety climate, whereas levels of provider burnout remained high. Program effectiveness was highly rated, and most projects showed qualitative improvements.

CONCLUSION

This study showed positive workplace culture change associated with the quality improvement intervention. Lessons learned from the implementation of this program can inform future quality improvement initiatives.