[Immediate consent directly after patient enlightening talk-valid or void? : Consider time for thought!] / Die sofortige Einwilligung unmittelbar nach dem Aufklärungsgespräch ­ wirksam oder unwirksam? : Bedenkzeit bedenken!

Patients must be informed of the chances of success and risks well in advance of the intended treatment measure so that they can adequately maintain a freedom of choice and thus the right to self-determination by carefully considering the reasons for and against the recommended measure. Fixed deadlines for the time between information and consent cannot be set as a blanket measure. There can be many different aspects that must be considered, which can lead to different deadlines in individual cases, which should lie between information, consent and the start of the measure. If a treatment measure does not have to be carried out immediately, a reflection period adapted to the circumstances should be allowed until shortly before the intervention. If this period of deliberation is not granted and consent is requested immediately, the doctor must convince himself before the treatment measure is carried out that the consent given still corresponds to the patient's will. This request is not necessary if the patient has expressly waived a period of reflection after receiving appropriate clarification.

[Legal quality criteria of expert opinions in liability for medical malpractice]. / Juristische Qualitätskriterien von Arzthaftungsgutachten.

In litigation regarding to liability for medical malpractice the court itself for lack of medical expert knowledge cannot judge a claimed error in treatment. That applies too for the question if there is causation between the error in treatment and claimed damage to patient's health. In this respect, the court is dependent on a medical expert and is bound to his assessment, unless there is no quality deficit in respect of medical and/or legal criteria. The more the medical expert knows the legal background of physician's liability for medical malpractice, the less is the risk of legal quality deficits in his expert opinion and thereby also of judicial errors by court.

[Legal characteristics of expert opinions of anaesthetic cases of the North German Arbitration Board]. / Gutachtenfälle - Juristische Besonderheiten bei der Begutachtung anästhesiologischer Fälle der Norddeutschen Schlichtungsstelle.

The Arbitration Board for Medical Liability Issues of the State Medical Councils of Northern Germany in Hannover (North German Arbitration Board, NGAB) settles about 100 cases in the area of anaesthesiology per year. In these proceedings the patient carries the burden of proof. I. e. the patient has to prove that its health damage was caused by a medical error. Nevertheless, for individual cases the NGAB examines also whether facilitation of the burden of proof can be granted to the patient. This article exemplifies cases, for which the NGAB recognized such facilitation of the burden of proof. In each of these cases, the NGAB asserted the damage claim.

[Selected medical closed claims in the field of regional anaesthesia]. / Gutachtenfälle - Gutachtenbeispiele aus der Regionalanästhesie.

Legal malpractice cases in regional anaesthesia comprise a significant number of all cases before the expert commissions and arbitration boards of the state medical associations. One reason for this is the increasing use of neuraxial and peripheral regional blocks in orthopaedics and traumatology. Only in about one fourth of the reviewed cases could either a causal relationship between substandard performance and patient injury or an inadequate obtaining of informed consent be established. In the great majority of cases patients' claims were unfounded, since the patients' injuries were adjudged to be unavoidable and adequate consent had been abtained prior to performance of the blocks.

[Delayed appendectomy because of diagnostic malpractice: Experiences of the Arbitration Board of the North German Medical Associations]. / Die durch Diagnosefehler bedingte Verzögerung der operativen Behandlung der akuten Appendizitis - Erfahrungen der Norddeutschen Schlichtungsstelle für Arzthaftpflichtfragen.

From 2000 to 2012, 447 panel proceedings concerning acute appendicitis were evaluated. 271 cases (57 %) were related to alleged diagnostic malpractice. This was confirmed in 176 cases (67 %). The following medical specialities were involved (m = quote of malpractice): general surgery 33 %, m = 51 %; paediatric surgery 3 %, m = 44 %; general practitioner and prehospital emergency services 24 %, m = 62 %; internal medicine 19 %, m = 70 %; paediatrics 13 %, m = 57 %; gynaecology 3 %, m = 91 %; urology 2 %, m = 17 %. The most frequent misdiagnosis was gastroenteritis (43 % in adults, 69 % in children), obviously based on the concomitant symptom of diarrhoea. Surgery revealed all stages of advanced appendicitis up to peritoneal sepsis, organic failure and death (n = 5). The evaluation of the files and the experts' reports of the 176 cases of diagnostic malpractice allowed to define the following basic failures, which led to unjustified delay of operation: careless history-taking, no or incomplete physical examination, no follow-up investigations, incorrect interpretation of the patient's complaints and clinical findings, no or incomplete documentation. Conducting a thorough investigation is essential to avoiding diagnostic malpractice. Internal analysis of failures or near failures may contribute to reducing the number of future cases of malpractice.

[Anaesthetic incidents - Airway management and injuries in anaesthesia - closed claims of the North German Arbitration Board]. / Anästhesiezwischenfälle - Atemwegsmanagement und Schäden in der Anästhesie - "closed claims" der Norddeutschen Schlichtungsstelle.

Injuries related to the airway management belong to the most often observed anaesthesia-related complications. Injuries of the trachea and the oesophagus possibly require surgical treatment. The most severe injuries caused by the airway management are the hypoxic brain damage and the patient's death. Tracheal injuries happen foremost as a result of tracheal intubation. Symptoms like subcutaneous emphysema and dyspnea are likely a sign of a tracheal lesion and need to be examined by Thorax-CT and endoscopy of the airways. In order to avoid injuries, medical treatment has to be applied with the appropriate care and strict adherence to the manufacturer's requirements regarding the use of the assisting devices necessary for the tracheal intubation. While some of he cases presented have to be assessed as of fateful origin, others are clearly the results of medical errors.

[Anaesthics incidents - Injuries caused by regional anaesthesia - closed claims of the North German Arbitration Board]. / Anästhesiezwischenfälle - Schäden durch Regionalanästhesie - "closed claims" der Norddeutschen Schlichtungsstelle.

Injuries caused by regional anaesthesia are the second most common reason for a patient to apply to the North German Arbitration Board. Part of the reported injuries are mild and transient, while others are severe and permanent, e.g. a paraplegia after regional anaesthesia. In the majority of the reported cases, the Arbitration Board did not find a medical error as cause of the injury. Nevertheless, every possible effort needs to be made to reduce the number and the severity of the injuries due to regional anaesthesia. In order to reach that goal, medical treatment has to be applied with the appropriate care, including the strict adherence to the height of puncture for epidural and spinal anaesthesia below the Conus medullaris and the use of assisting devices like nerve stimulator and ultrasound-guided puncture. Using these measures, the frequency of injuries caused by regional anaesthesia will be reduced.

Out of court settlement of malpractice claims relating to the treatment of fractures in children: experience of the arbitration board of the North German Medical Associations.

BACKGROUND: The medical peer-review committees and arbitration boards of the Medical Associations of the individual German federal states assess claims for damages arising from alleged medical malpractice. METHODS: 189 panel proceedings concerning alleged malpractice in the treatment of fractures in children were evaluated on the basis of the available documentation and decisions. The proceedings were evaluated with respect to the involved medical specialties and treatment facilities, the types of fracture and particular allegations in each case, the actual malpractice found to have been committed (if any), and the harm resulting from malpractice. The cases were derived from the nine German states for which the North German arbitration board is responsible. RESULTS: An actual malpractice was found to have been committed in 64% of cases, or about twice as frequently as the average rate among all cases going before an arbitration board in Germany. Most of the medical errors involved inaccurate diagnostic evaluation, misinterpretation of radiological findings, inappropriate treatment for the particular type of fracture involved (conservative rather than operative, or vice versa), or inadequate follow-up of the fracture (or none at all). The highest rate of a positive finding of malpractice involved fractures in the elbow region (77%). A mild or moderate degree of permanent injury due to malpractice was found in 37 cases (31%) and severe permanent injury in 16 cases (13%). CONCLUSIONS: The appropriate treatment of fractures in children requires experience in clinical examination as well as knowledge of radiological anatomy and of the problematic fracture types and localizations. The results reported here should raise consciousness of the possibilities for medical error and thus help prevent future instances of malpractice.

[The frequency of medical malpractice: the results of the German Expert Panels and Arbitration Boards for Medical Liability]. / Ergebnisse der Gutachterkommissionen und Schlichtungsstellen.

The Gutachterkommissionen and Schlichtungsstellen in Germany (Expert Panels and Arbitration Boards for Medical Liability) were founded in the 1970s in order to serve as an institution other than the courts where suspected incidents of malpractice can be evaluated. The "Medical Error Reporting System" (MERS) was developed by the North German Schlichtungsstelle. The data it provides serve as the basis for the national statistics published by the Bundesärztekammer (German Medical Association). 7201 factual decisions were made. In 5074 proceedings no malpractice cases or risk disclosure problems were discovered, while in 2127 proceedings either of the two problems was noticed, and in 1,683 proceedings these problems were rated as being causative in the claimed harm and led to the recommendation to grant financial compensation to the patient. The MERS data reveal that most of the diagnoses which led patients to file a claim with the Gutachterkommissionen and Schlichtungsstellen referred to orthopaedics and traumatology and in the majority of cases reproaches were directed at surgical therapy. Doctors must strive to minimise malpractice and harm caused by medical treatment. With the help of the national statistics of the Bundesärztekammer derived from MERS the doctor can easily access information on cases of medical malpractice and harm in his or her discipline. This knowledge helps to foresee risks in a patient's treatment and to avoid errors.

[Malpractice claims relating to the diagnosis and treatment of acute appendicitis--decisions of the Norddeutsche Schlichtungsstelle (Expert Panel for Extrajudicial Claims Resolution of the Medical Associations in Northern Germany)]. / Arzthaftpflichtverfahren im Zusammenhang mit der Diagnose und der Therapie der akuten Appendizitis. Erfahrungen der Schlichtungsstelle der norddeutschen Arztekammern.

During the five years between 2000 and 2004 the Norddeutsche Schlichtungsstelle decided on 241 malpractice claims relating to the diagnosis and treatment of acute appendicitis including 220 hospitals and 60 primary care outpatient facilities. 29 claims involved two and 5 claims involved three physicians/hospitals. One third of the 241 claims were related to non-surgical specialties. The rate of negligent adverse events was 117/241 (49%); surgeons accounted for 41% of the claims, and non-surgeons for 67%; 46% of the claims involved hospitals, and 65% outpatient facilities. There were 127/241 (53%) cases of perforated appendicitis; and in 90% of these cases the patients complained of delayed diagnosis and/or operation. In the 114/241 (47%) cases with non-perforated appendicitis patients complained of errors related to operative procedures, of delayed re-interventions and of non-surgical complications. The degree of disability was determined in all cases of iatrogenic injury due to medical negligence: the impairment was transient and minimal to moderate in 67 of injured patients; transient and serious in 35, permanent and serious impairment in 12 cases, and 3 patients died (another 2 cases of deaths were unrelated to negligence or iatrogenic injury). Outstanding errors documented in these cases of appendicitis included: failure to conduct a follow-up examination within 12-24 hours; delayed re-intervention for peritonitis or peritoneal abscess. Puncture lesions of the bowel or great vessels due to iatrogenic injury acquired in the course of laparoscopic appendectomy were reported in 8 cases.

[Medical risk and iatrogenic injury--"accident reports" from the North German Schlichtungsstelle (expert panel for extrajudicial claims resolution)]. / Behandlungsrisiko und iatrogener Schaden--"Unfallberichte" aus der Norddeutschen Schlichtungsstelle.

Schlichtungsstellen and Gutachterkommission--expert panels for extrajudicial malpractice claims resolution--are well positioned to provide data on iatrogenic injuries and negligence in medical care, based on the information collected from a great number of panel cases. Within the last 4 years, 2000 through 2003, the Norddeutsche Schlichtungsstelle concluded 10,513 Schlichtungsverfahren (panel proceedings), more than three quarters of them related to the surgical specialties; most of the claims addressed operations and postoperative therapy. In the nonsurgical specialities, the highest proportion of the proceedings had to do with procedures. These results are similar to those of population-based studies of adverse events by chart review. Decisions in favor of the patient were given in 25-30% of all the cases. But the proportion of all treatment-induced injuries determined in the proceedings of the Schlichtungsstelle amounted to 50-60% of all cases, and to more than 70% if operations or medical procedures were the medical problems in question. In cases where negligence was involved, most frequently diagnostics were at fault (the highest rate of errors was found in diagnostic radiology and imaging techniques), followed by injurious errors of operative technique and postoperative care. The risks of medical injury in older patients and of drug-induced adverse events are underrepresented in the cases of the Schlichtungsstelle. Deficient doctor-patient communication, claimed by about 25% of the patients in their initial correspondence to the panel, can only rarely be proved or disproved by documentation. Nevertheless, these deficits play an important role as risk factors for negligence and injury and even as causes of dispute and claims. In addition to communication with the patient, open and honest communication--and confidentiality--within the medical team are essential in managing the risks of error and injury in medical care.