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.

Medico-Legal Cases Involving Cardiologists and Cardiac Test Underuse or Overuse.

BACKGROUND: Evidence-based campaigns are available to support appropriate diagnostic testing in cardiology, but medico-legal concerns can impede implementation. METHODS: We conducted a retrospective descriptive analysis of medico-legal cases (civil legal, regulatory authority, hospital matters) involving cardiologists in Canada. For eligibility, cases must have closed at the Canadian Medical Protective Association between January 1, 2009 and December 31, 2018. We defined test underuse and overuse using criticisms in the medico-legal record from peer experts, regulatory authorities, or hospitals. We used a contributing factors framework and descriptive statistics for analysis. RESULTS: From 2009 to 2018, the Canadian Medical Protective Association closed 60,598 cases with 368 (0.6%) involving a cardiologist. Within those cases, there was no criticism of cardiac diagnostic test overuse and 15 cases (4.1%) with criticism of underuse (tests not ordered, not expedited, delayed). In 12 of 15 cases of underuse (80.0%), the patient experienced severe harm or death. Of 8 civil legal cases, 6 were decided in favour of the plaintiff (75.0%) and 2 were dismissed by consent before proceeding to trial (25.0%). Decisions on regulatory authority matters did not favour the cardiologist (7 of 7 cases). In all cases of underuse, there was need for focused testing to investigate new or worsening symptoms. The most common contributing factors included clinical decision-making, situational awareness, and communication with teams and patients. CONCLUSIONS: Medico-legal cases involving cardiologists and the overuse or underuse of cardiac diagnostic tests were extremely rare in Canada, despite the potential for harm. The criticisms of cardiac diagnostic test underuse related to issues with diagnosing symptomatic patients.

CONTEXTE: Même s'il existe des campagnes fondées sur des données probantes visant à promouvoir le recours aux tests diagnostiques appropriés en cardiologie, il arrive que des préoccupations d'ordre médico-légal nuisent à la réalisation de ces tests. MÉTHODOLOGIE: Nous avons réalisé une analyse descriptive rétrospective des affaires médico-légales (poursuites au civil et plaintes déposées auprès d'organismes de réglementation et d'hôpitaux) touchant des cardiologues au Canada. Ont été retenus pour l'analyse les dossiers clos à l'Association canadienne de protection médicale entre le 1er janvier 2009 et le 31 décembre 2018. La sous-utilisation et la surutilisation de tests ont été définies à partir des critiques formulées dans les dossiers médico-légaux par des pairs spécialistes, des organismes de réglementation ou des hôpitaux. L'analyse reposait sur un cadre décrivant les facteurs contributifs et sur un modèle de statistique descriptive. RÉSULTATS: De 2009 à 2018, l'Association canadienne de protection médicale a clos 60 598 dossiers; de ce nombre, 368 (0,6 %) dossiers visaient un cardiologue. Parmi ces dossiers, aucun ne concernait la surutilisation de tests visant à diagnostiquer un trouble cardiaque, et 15 (4,1 %) concernaient la sous-utilisation de tels tests (test non demandé, non accéléré ou reporté). Dans 12 (80 %) des 15 cas de sous-utilisation, le patient a subi un tort grave ou est décédé. Sur les huit poursuites au civil, six (75 %) ont été jugées en faveur du demandeur, et deux (25 %) ont été rejetées d'un commun accord entre les parties avant le début du procès. Toutes les décisions relatives à des questions relevant des organismes de réglementation, au nombre de sept, ont été en défaveur du cardiologue. Dans tous les cas de sous-utilisation, le patient avait besoin de subir des tests ciblés afin d'évaluer l'apparition ou l'aggravation de symptômes. Les facteurs contributifs les plus fréquents comprenaient la prise de décisions cliniques, la connaissance de la situation et la communication avec les équipes et les patients. CONCLUSIONS: Les affaires médico-légales touchant des cardiologues et la surutilisation ou la sous-utilisation de tests de diagnostic cardiaque étaient extrêmement rares au Canada, malgré les préjudices qui peuvent en découler. Les critiques relatives à la sous-utilisation des tests de diagnostic cardiaque concernaient toutes des problèmes liés à l'investigation diagnostique chez des patients présentant des symptômes.

Using medicolegal data to support safe medical care: A contributing factor coding framework.

OBJECTIVE: Traditional medicolegal data analysis focuses on physician care, without a full acknowledgment of the effects of team, organizational, and system factors. We developed a patient safety-informed contributing factor framework to strengthen the coding and analysis of medicolegal data. MATERIALS AND METHODS: We incorporated patient safety theory and human factors science into our medicolegal case coding practices to improve our understanding of the many factors that contribute to medicolegal events. RESULTS AND DISCUSSION: A new framework was developed that has at its core, patients and their experience, and looks beyond the provider factors that are often the focus of medicolegal analysis to give greater consideration to the influence of team, organizational, and system factors. We anticipate that this substantial shift will strengthen our knowledge translation efforts to help improve the safety of medical care. CONCLUSION: We believe that reframing medicolegal case coding systems to better identify the influence of team, organizational, and system factors will increase the utility of this analysis in patient safety research, and health care quality improvement.