California's nurse-to-patient ratio law and occupational injury.

OBJECTIVE: To determine whether state-mandated minimum nurse-to-patient staffing ratios in California hospitals had an effect on reported occupational injury and illness rates. METHODS: The difference-in-differences method was applied: The change in injury rates among hospital nurses after implementation of the law in California was compared to the change in 49 other states and the District of Columbia combined. Data were drawn from the US Bureau of Labor Statistics and the California Employment Development Department, including numerator estimates of injury and illness cases and denominator estimates of the number of registered nurses (RNs) and licensed practical nurses (LPNs) employed in hospitals. Confidence intervals (CIs) for rates were constructed based on assumptions that favored the null hypothesis. RESULTS: The most probable difference-in-differences estimate indicated that the California law was associated with 55.57 fewer occupational injuries and illnesses per 10,000 RNs per year, a value 31.6 % lower than the expected rate without the law. The most probable reduction for LPNs was 38.2 %. Analyses of CIs suggested that these reductions were unlikely to be due to chance [corrected]. CONCLUSIONS: Despite significant data restrictions and corresponding methodological limitations, the evidence suggests that the law was effective in reducing occupational injury and illness rates for both RNs and LPNs. Whether these 31.6 and 38.2 % reductions are maintained over time remains to be seen [corrected].

Trends in Hospital Lawsuits Filed Against Patients for Unpaid Bills Following Published Research About This Activity.

Importance: Suing patients and garnishing their wages for unpaid medical bills can be a predatory form of financial activity that may be inconsistent with the mission of a hospital. Many hospitals in the state of Virginia were discovered to be suing patients for unpaid medical bills, as first presented in a 2019 research article that launched 2.5 months of media attention on hospital billing practices and a grassroots public demand for hospitals to stop the practice. Objective: To evaluate the association of a research publication and subsequent media coverage with the number of hospital lawsuits filed against patients for unpaid medical bills. Design, Setting, and Participants: This cross-sectional study of Virginia hospitals that sued patients for unpaid medical bills used an interrupted time series analysis. Data on hospitals suing patients for unpaid medical bills were collected during a preintervention period (June 25, 2018, to June 24, 2019), an intervention period (June 25, 2019, to September 10, 2019), and a postintervention period (September 11, 2019, to September 10, 2020). Exposures: Publication of a research article and subsequent media coverage. Main Outcomes and Measures: The total number of warrant in debt and wage garnishment lawsuits filed by Virginia hospitals and the frequency of those lawsuits filed before, during, and after the intervention period on a weekly basis. Results: A total of 50 387 lawsuits, filed by 67 Virginia hospitals, were included; 33 204 (65.9%) were warrant in debt lawsuits, and 17 183 (34.1%) were wage garnishment lawsuits. From the preintervention period to the postintervention period, there was a 59% decrease in the number of lawsuits filed (from 30 760 lawsuits to 12 510 lawsuits), a 55% decrease in the number of warrant in debt cases filed (from 19 329 to 8651), a 66% decrease in the number of wage garnishments filed (from 11 431 to 3859), and a 64% decrease in the dollar amount pursued in court (from $38 700 209 to $13 960 300). During the study period, 11 hospitals banned the practice of suing patients for unpaid medical bills. The interrupted time series analysis showed a significant decrease of 5% (incidence rate ratio, 0.95; 95% CI, 0.94-0.96) in the total weekly number of lawsuits in the postintervention period. Conclusions and Relevance: The findings of this study suggest that research leading to public awareness can shift hospital billing practices.

The medico-legal implications in medical malpractice claims during Covid-19 pandemic: Increase or trend reversal?

The Covid-19 pandemic caused a marked increase in admissions to intensive care units. The critically ill patients' condition from the infection resulted in their deaths. The healthcare facilities have got into trouble because of the pandemic. In fact, they had to create additional beds in a very short time and to protect health workers with personal protective equipment. Healthcare professionals fear that there will be an increase in complaints and medico-legal malpractice claims and hence they have urged politicians to discuss this. The Italian Parliament recently debated the topic of medical liability and passed the Decree-Law no. 18 of 17 March 2020 (DL - so called Cura Italia) by which they want to extend the concept of "gross negligence" to healthcare facilities. Several Extended Care Units have suffered from outbreaks of Covid-19, so the Prosecutor's Office of several cities initiated investigations against them. This situation has reached Sicily, where the Prosecutor's Office of Palermo has opened an inquiry against an Extended Care Unit. Simultaneously, the Covid-19 pandemic may change patients' attitudes towards healthcare professionals, who are risking their lives daily. So the Italian medico-legal community is debating these questions, with one last pending question remaining: is the number of medico-legal claims likely to increase or trend down?

Regulation on introducing process of the highly difficult new medical technologies: A survey on the current status of practice guidelines in Japan and overseas.

Since serious problematic cases regarding the technical safety of technically demanding operations were reported in Japan, the Ministry of Health, Labor and Welfare issued new regulations on June 10, 2016 requiring each hospital to check the status of informed consent, skill of surgery team and governance system of the surgical unit, when the highly difficult new medical technologies were introduced to a hospital. In order to firmly establish this new system for highly difficult new medical technologies, it is very important and informative to survey the current situation for guidelines and consensus regarding introduction of medical technology with special skills in Japan and overseas. Based on the survey of questionnaires, document retrieval, and expert interviews, we found that documentation related to the introduction process of highly difficult medical technologies is very rare, and the regulations were mainly issued by academic societies. Moreover, even if such documentation existed, the quality of the regulations is poor and not sufficient enough to perform surgical practice safely. Therefore, for medical practitioners, comprehensive and concrete regulations should be issued by the government or ministry to legally follow in regard to technically demanding operations. A new practice guideline was proposed by our special research group to regulate the introduction process of highly difficult new medical technologies in hospitals in Japan. This guideline, gained understanding from relevant academic societies, provided a comprehensive view on the interpretation of "high difficulty new medical technology" prescribed by the law and show the basic idea at a preliminary examination from the viewpoints of "Surgeon's requirement", "Guidance system", "Medical safety" , and "Informed consent". These efforts will contribute to the improvement of the quality of guidelines regarding "highly difficult new medical technology".

[Estimation of medical protocol correctness in the light of opinions issued as ordered by the judiciary or prosecution authorities]. / Ocena prawidlowosci postepowania lekarskiego w swietle opinii wydanych na zlecenie wymiaru sprawiedliwosci lub organów scigania.

UNLABELLED: Medical personnel, most commonly physicians, are held responsible for situations in which in the course of medical treatment some adverse effects develop that endanger the patient's health and life. Such effects generally include death, a severe damage to patient's health as well as the exposing of patients to the danger of such effects developing in them. The effects of the kind result either from some medical malpractice or from medical personnel's negligence. The aim of the paper was to analyse medico-legal expertises issued as ordered by the Polish Judiciary and Prosecution Authorities in cases of alleged medical malpractice that had been issued by the Chair and Department of Forensic Medicine, Medical University of Gdansk, and to compare the results with those from similar studies done by Chairs and Departments of Forensic Medicine at the Medical Universities of Katowice, Kraków, and Wroclaw. MATERIAL AND METHODS: Analysis was done of 372 medico-legal expertises issued in the years 1990-2004 by the Chair and Department of Forensic Medicine, Medical University of Gdansk. The results obtained were compared with those from a similar analysis of medicolegal expertises issued in Gdarisk in the years 1968-1977 and also with those from studies presented by Departments of Forensic Medicine at the Medical Universities of Katowice, Kraków, and Wroclaw. RESULTS: Legal proceedings were generally conducted by the Public Prosecutor's Office, less frequently by the police, and only in 7.2% were such cases subject to the civil law procedure. Most frequently assessed health care facilities included hospitals (66.1%), clinics of medical universities (16.6%), and ambulance service (13.4%). Seldom were the charges of medical malpractice brought against basic health care facilities (9.4%) or private practices (3.5%). As revealed in the analyzed material, adverse health effects of a disease or injury included death--70.5%, a severe damage to patient's health--9.1%, and the endangering of patients with development of such effects--0.4%. In 60.8% of the cases analyzed, medical protocol implemented by medical personnel was assessed as proper. Medical malpractice were found in 18.5% of the cases, including diagnostic malpractice--1.8% therapeutic malpractice--2.7%, and those of logistic nature--4%. Similar results were obtained by the above mentioned Departments of Forensic Medicine. Negligence in the rendering of health care was found in 13.4 of the medico-legal expertises analyzed. Conclusions. In the material subjected to this analysis criminal cases are predominant. Medical personnel, including medical practitioners, are more and more frequently charged with exposing patients to the immediate danger of loss of life or a severe damage to their health (Art. 160 of the Polish Penal Code). There are more and more cases in which the adverse effects endangering patient's health or life result from negligence rather than from some medical malpractice.

An Assessment of Hospital-Based Palliative Care in Maryland: Infrastructure, Barriers, and Opportunities.

CONTEXT: Maryland recently passed legislation mandating that hospitals with more than 50 beds have palliative care (PC) programs. Although the state's health agency can play a key role in ensuring successful implementation of this measure, there is little actionable information from which it can guide resource allocation for enhancing PC delivery statewide. OBJECTIVES: To assess the PC infrastructure at Maryland's 46 community-based nonspecialty hospitals and to describe providers' perspectives on barriers to PC and supports that could enhance PC delivery. METHODS: Data on PC programs were collected using two mechanisms. First, a survey was sent to all 46 community-based hospital chief executive officers by the Maryland Cancer Collaborative. The Maryland Health Care Commission provided supplementary survey and semistructured interview data. RESULTS: Twenty-eight hospitals (60.9%) provided information on their PC services. Eighty-nine percent of these hospitals reported the presence of a structured PC program. The profile of services provided by PC programs was largely conserved across hospital geography and size. The most common barriers reported to PC delivery were lack of knowledge among patients and/or families and lack of physician buy-in; most hospitals reported that networks and/or conferences to promote best practice sharing in PC would be useful supports. CONCLUSION: Systematic collection of state-level PC infrastructure data can be used to guide state health agencies' understanding of extant resources and challenges, using those data to determine resource allocation to promote the timely receipt of PC for patients and families.

[No spectacular rise in claims for medical damages in The Netherlands: 1993-'01 compared to 1980-'90]. / Geen spectaculaire ontwikkeling van medische schadeclaims in Nederland: 1993/'01 in vergelijking met 1980/'90.

OBJECTIVE: To acquire insight into the number and nature of claims for damages that were filed in the period 1993/'01 in hospitals insured by MediRisk and to compare this with the period 1980/'90. DESIGN: Descriptive. METHOD: Data were collected from the registration system for insurance claims maintained by MediRisk, an insurer of medical liability risks. The data were processed up to and including 31 October 2002. There were 4058 claims in 3316 closed and 742 open dossiers. The results were compared with those from a comparable investigation into the period 1980/'90 (3970 claims; 1550 dossiers investigated). The number of invasive medical interventions in the period 1990-2001 was obtained from Prismant in Utrecht. Study of the dossiers yielded information about the use of legal procedures. RESULTS: Compared to 1980/'90 there was a 34% increase in the number of claims for damages following medical interventions during the period 1993/'01. This increase was smaller than the growth in the number of high-risk interventions (47%). The percentage of rejected claims for damages was 6o in the period 1980/'90 and 68 in 1993/'01. In both periods, most of the claims pertained to surgical specialisms, in particular general surgery. In 370 of the 3316 closed dossiers (11%) a legal procedure was mentioned: complaints committee (5%; in 1980/'90 hospitals were not required to have a complaints committee), civil court (3%; this was 4% in 1980/'90) and the Medical Disciplinary Board (3%; this was 6% in 1980/'90). CONCLUSION: The increase in the number of claims for damages filed against hospitals insured with MediRisk was limited compared to the number of medical interventions carried out. The number of legal procedures arising from these claims did rise in the absolute sense, but fell in relation to the number of claims for damages.

Implementation of the Patient Self-Determination Act: a survey of Nebraska hospitals.

The purpose of this survey of Nebraska hospitals (N = 79) was to describe the planning, implementation, and evaluation of the Patient Self-Determination Act (PSDA) and to explore the role of the nurse in these processes. Results indicate nurses were very involved in the planning phase but rarely in the implementing phase. Few evaluation strategies were utilized and only some respondents identified problematic issues related to the implementation of the PSDA. Clinical implications for issues related to the PSDA are discussed and framed within the American Nurses' Association Position Statement on the PSDA (1991). Future studies are suggested, especially related to evaluation of PSDA implementation.