Two sides of the same coin: educational and professional pathway for surgical residents.

AIM: To provide a review of medical malpractice cases ruled by the Italian Supreme Court with the aims at identifying lawsuits targeting involved with surgical residents. MATERIAL AND METHODS: Legal cases ruled by the Italian Supreme Court, from September 2020 to October 2020, pertaining to medical claims involving surgical residents were examined, using the main online databases. RESULTS: Of a total of eleven (n=11; 100%) cases identified, four (n= 4; 36,4%) cases addressed the standard of care pertaining to the surgical residents' medical activity. The legal reasoning of the Italian Supreme Court does not focus on the manual skill in the resident's medical performance, but rather on the choice to accept to treat the patient, regardless of the participation of the tutor. CONCLUSIONS: The performance of the surgical residents is made more difficult due to their peculiar nature, characterized by the complex interactions between the directives given by the tutor and the need to guarantee patients' needs. KEY WORDS: Surgical Residents, Tutor, Educational Pathway, Medical Malpractice, Standard of Care.

Litigation in Hand Surgery: A 30-Year Review.

BACKGROUND: Although hand surgery is generally safe and effective, some patients experience complications or poor outcomes prompting them to seek compensation. This study reviews malpractice claims in hand surgery using a national data set to assess reasons for litigation and identify predictors of outcome. METHODS: The Westlaw database was queried for cases related to hand surgery and medical malpractice between 1989 and 2018. Jury verdicts and settlements were reviewed for relevance, and variables including plaintiff and defendant demographics, diagnosis, alleged reason for malpractice, verdicts, and payouts were recorded. RESULTS: Four hundred thirty relevant claims were identified. Distal radius fractures (21 percent), carpal tunnel syndrome (14 percent), and tendon lacerations (6 percent) were the most common diagnoses. Alleged reasons for malpractice included failure to diagnose/treat (34 percent), surgical negligence (29 percent), and improper procedure/treatment (19 percent). Thirty-six cases (8 percent) resolved in settlement for a mean payout of $551,957. A plaintiff verdict was reached in 98 cases (25 percent of trials), with a mean payout of $832,258. The remaining 296 cases (75 percent of trials) resulted in defendant verdicts (no payout). Plaintiff age, plaintiff sex, defendant sex, and defendant degree had no impact on trial outcome. Cases involving surgeons without subspecialty certification in hand surgery were significantly more likely to result in plaintiff verdicts (27 percent versus 7 percent with hand subspecialization; p = 0.003). CONCLUSIONS: This study reviews malpractice claims in hand surgery over the past 30 years. Providing timely diagnoses, managing expectations, and reducing procedural error may decrease the risk of litigation.

Canadian Association of Pediatric Surgeons' state of wellness.

The following is a summary of the fourth Ein Panel Debate Session from the 50th Annual Meeting of the Canadian Association of Pediatric Surgeons (CAPS) held in Toronto, ON, from September 26-29, 2018. The session focused on surgeon well-being at different stages of career: role of mentorship at the start of career, second victim syndrome, litigation stress syndrome, and retirement. Using Maslach Burnout Inventory Survey, CAPS members were presented their wellness scores as a group compared to other health care providers. The power of surgical culture in influencing decision making and judgment was explored. A culture shift toward vulnerability and transparency is possible and more suitable to expert practice and surgeon wellness.

Learning from lawsuits: Ten-years of NHS litigation authority claims against 11 surgical specialities in England.

INTRODUCTION: Medico-legal claims are a drain on NHS resources and promote defencive practice. The litigious burden of surgery in England has not been previously described. This paper describes trends over ten years of claims made against the NHS across 11 surgical specialities. MATERIALS AND METHODS: Data were requested for all claims received by the NHS Litigation Authority (NHSLA) from 2004 to 2014. Surgical specialities included cardiothoracic, general, neurosurgery, obstetric, oral and maxillofacial (OMFS), orthopaedic, otorhinolaryngology, paediatric, plastic, urology and vascular surgery. A literature review of peer-reviewed publications was performed with search terms 'NHSLA' and 'Surgery'. RESULTS: The NHS paid out approximately £1.5 billion across 11 surgical specialities from 2004 to 2014. Orthopaedic, obstetric and general surgery received the largest number of claims per year, and paediatric surgery the least. The mean time from registration of claim with the NHSLA to settlement was 25.5 months (range 17.8 months-35 months). Neurosurgery was responsible for the highest average amount paid per claim, and OMFS the lowest. Failure/delay in treatment and/or diagnosis and failure to warn/adequately consent were the three leading types of claim. 806 never events were successfully claimed for during the ten-year period. DISCUSSION AND CONCLUSION: Sharing information and good practice should be a priority for surgical professionals. Lessons learnt from medico-legal claims are transferrable in strategic planning. This pan-speciality report has demonstrated considerable burden on the NHS and should promote improvement in practice on an individual level in addition to providing systems based recommendations to NHS and international organisations.

Dissecting malpractice in pancreaticoduodenectomy cases.

BACKGROUND: Medical malpractice is a growing concern for physicians in all fields. Surgical fields have some of the highest malpractice premiums and litigation rates. Pancreaticoduodenectomy (PD) has become a popular procedure; however, it is still associated with significant morbidity and mortality. This study is the first to analyze factors involved in litigation regarding PD cases. METHODS: The Westlaw database was searched for jury verdicts and settlements using the terms "medical malpractice" and "pancreaticoduodenectomy". Twenty-nine cases from 1991 to 2012 were initially collected. Seven entries not involving PD and three duplicate cases were excluded. Nineteen cases were included for analysis. RESULTS: Of the 19 cases included in the analysis, three (15.8%) reached a settlement, three (15.8%) were ruled in favor of the plaintiff, and 13 (68.4%) were ruled in favor of the physician. The average settlement award was $398,333 (range, $195,000-500,000), and the average plaintiff award was $4,288,869 (range, $1,066,608-10,300,000). The most common factors raised in litigation included PD being allegedly unnecessary (47.4%), followed by postoperative negligence and misdiagnosis (36.8% each). CONCLUSIONS: The most common factors present in litigation included the allegation that PD was unnecessarily performed. The cases that are awarded large monetary sums are those that involve continued medical care. Ways to improve patient safety and limit litigation include increasing transparency and communication with a thorough discussion between surgeon and patient of the most common topics of litigation discussed.

NHS litigation in bariatric surgery over a ten year period.

Negligence claims in the UK NHS has increased over the last 30 years. The aim of this present study was determine the number of claims and the cost of litigation in Bariatric Surgery and compare it to similar other specialties. Data was received from NHS Litigation Authority (NHSLA) in response to Freedom of Information data request. There was a total of 7 claims, of which 4 were successful. The total pay out sum was £210,000 in 10 years. This is a very low amount compared to other surgical specialties. This low level of litigation probably indicates that the current bariatric surgical services in the NHS are delivering safe care with good patient satisfaction. This needs to be carefully considered prior to changing the payment tariffs for bariatric surgery.

Tipping the scales: educating surgeons about medical malpractice.

BACKGROUND: In Pennsylvania, medical malpractice premiums are a major cost to surgeons. Yet surgeons often have little if any education in the basics of tort litigation or how to manage their risk. This work describes one approach for educating academic faculty surgeons on current concepts of medical malpractice and provide some guidance on how to "tip the scales of justice"; or minimize the risks of being named in a malpractice claim. MATERIALS AND METHODS: The course had five parts: the basics of medical malpractice, the cost of malpractice insurance, current departmental claims experience, strategies for decreasing the risk of being named in a claim, and an overview of malpractice reforms. An anonymous seven question survey was cast in a five-point Likert scale format. A weighted average of 4.5 or above was considered satisfactory. Two free text questions asked about positive and negative aspects of the course. RESULTS: Eighty of 95 (84%) faculty attended either in person or by reviewing a web-based video. Quantitatively, five of seven questions had a weighted average of more than 4.5 (n = 48, response rate = 60%). Qualitatively, the course was reviewed very favorably. CONCLUSIONS: The high percentage of participation and overall survey results suggest that the course was successful. This course was one facet of an approach to decrease the risk of malpractice claims. Unique aspects of this course include an emphasis on state law, department-specific data, and strategies to minimize risk of future claims. Given the state-specific nature of malpractice claims and litigation, individual departments must particularize similar presentations.

[What went wrong? Analysis of Medical Malpractice Arbitration Proceedings Conducted by a German Arbitration Board after Breast Reductions]. / Was geht schief? Schlichtungsverfahren nach Mammareduktionen - eine Analyse der Eingriffe mit Behandlungsfehler und Haftungsanspruch der Norddeutschen Schlichtungsstelle.

INTRODUCTION: The Arbitration Board for Medical Liability Issues of the Medical Association of North Germany ("Norddeutsche Schlichtungsstelle") is responsible for 10 federal states in Germany (Berlin, Brandenburg, Bremen, Hamburg, Mecklenburg-Western Pomerania, Lower Saxony, Saarland, Saxony-Anhalt, Schleswig-Holstein and Thuringia) and is the largest arbitration board in Germany. The data available from the Norddeutsche Schlichtungsstelle provides an insight into sources of malpractice during the treatment of reduction mammoplasty. MATERIAL UND METHODS: We analysed patient request, expert opinions prepared by independent physicians on behalf of the Norddeutsche Schlichtungsstelle and the final verdicts of 88 arbitration proceedings after breast reduction mammoplasties performed between 2000 and 2007. This data allows for each case to be addressed from different viewpoints. Furthermore we analysed the statistical data entered into the Medical Error Reporting System by the arbitration board. RESULTS: Among the 88 patient requests after reduction mammoplasty, the arbitration board found a causal relationship between damage caused to a patient's health and medical malpractice in 37 cases. Therefore, 42% of requests resulted in a liability case. This is a higher rate than that of general arbitration proceedings, where only in 24% of all cases a causal relationship is confirmed by the Norddeutsche Schlichtungsstelle. Most patients were operated on by gynaecologists. In 92% of liability cases, mistakes happened during the planning and the performance of the surgical procedure, mainly during planning (65%) and surgical incisions (41%). The patients mainly complained about scars (78%), asymmetry (68%) and skin necrosis of the areola (24%). Financial disadvantage was mentioned less often (46%) than psychological stress (70%). DISCUSSION: The higher rate of liability claims may be due to the fact the surgical procedures changing the shape of breasts are more complex than generally expected. Not only the surgery itself, but also the adequate planning and aftercare are of predominant importance for patient satisfaction. All these factors lead to the relatively high rate of medical malpractice in plastic aesthetic breast surgery. Also the communication factor should not be underestimated.

[Wrong site surgery : Incidence, risk factors and prevention]. / Verwechselungseingriffe in der Chirurgie : Inzidenz, Risikofaktoren und Prävention.

BACKGROUND: Wrong site surgery defines a category of rare but totally preventable complications in surgery and other invasive disciplines. Such complications could be associated with severe morbidity or even death. As such complications are entirely preventable, wrong site surgery has been declared by the World Health Organization to be a "never event". MATERIAL AND METHODS: A selective search of the PubMed database using the MeSH terms "wrong site surgery", "wrong site procedure", "wrong side surgery" and "wrong side procedure" was performed. RESULTS: The incidence of wrong site surgery has been estimated at 1 out of 112,994 procedures; however, the number of unreported cases is estimated to be higher. Although wrong site surgery occurs in all surgical specialities, the majority of cases have been recorded in orthopedic surgery. Breakdown in communication has been identified as the primary cause of wrong site surgery. Risk factors for wrong site surgery include time pressure, emergency procedures, multiple procedures on the same patient by different surgeons and obesity. Check lists have the potential to reduce or prevent the occurrence of wrong site surgery. CONCLUSION: The awareness that to err is human and the individual willingness to recognize and prevent errors are the prerequisites for reducing and preventing wrong site surgery.

Clinical negligence claims in pediatric surgery in England: pattern and trends.

AIMS OF THE STUDY: We hypothesized that there has been an increase in the number of successful litigation claims in pediatric surgery in England. Our aim was to report the incidence, causes, and costs of clinical negligence claims against the National Health Service (NHS) in relation to pediatric surgery. MATERIALS AND METHODS: We queried the NHS Litigation Authority (NHSLA) on litigation claims among children undergoing pediatric surgery in England (2004-2012). We decided a priori to only examine closed cases (decision and payment made). Data included year of claim, year of payment of claim, payment per claim, paid-to-closed ratio, and severity of outcome of clinical incident. RESULTS: Out of 112 clinical negligence claims in pediatric surgery, 93 (83%) were finalized-73 (65%) were settled and damages paid to the claimant and 20 (18%) were closed with no payment, and 19 (17%) remain open. The median payment was £13,537 (600-500,000) and median total cost borne by NHSLA was £31,445 (600-730,202). Claims were lodged at a median interval of 2 (0-13) years from time of occurrence with 55 (75%) cases being settled within the 3 years of being received. The commonest reasons for claims were postoperative complications (n=20, 28%), delayed treatment (n=16, 22%), and/or diagnosis (n=14, 19%). Out of 73, 17 (23%) closed claims resulted in case fatality. Conclusion: Two-thirds of all claims in pediatric surgery resulted in payment to claimant, and the commonest reasons for claims were postoperative complications, delayed treatment, and/or diagnosis. Nearly a quarter of successful claims were in cases where negligence resulted in case fatality. Pediatric surgeons should be aware of common diagnostic and treatment shortfalls as high-risk areas of increased susceptibility to clinical negligence claims.

[Patients' Rights Act - Relevance for surgical disciplines]. / Das Patientenrechtegesetz.

The new Patients' Rights Act does not reflect rights of patients as professional obligations of physicians for the first time. It adopted common longtime jurisdiction, but in some respects it is going beyond. This law clearly extends the documentation requirements of physicians, especially concerning the extent of documentation. In surgical fields the requirements for enlightening physicians were more strongly worded than in previous jurisdiction. In medical facilities it is now mandatory to establish an internal quality management system.

[Medical care unit -- a suitable instrument for ambulatory patient-adequate care and performance-related remuneration]. / Medizinisches Versorgungszentrum - geeignetes Instrument der ambulanten patientenadäquaten Versorgung und leistungsgerechten Vergütung.

BACKGROUND: The question of whether a medical care unit is an appropriate tool for outpatient care has been discussed for a long time. Our aim is to investigate whether the MCU is an effective instrument for outpatient care and adequate performance-related remuneration. MATERIAL AND METHODS: This retro- and prospective overview of the work included statements on legal foundations for medical care units, for reimbursement of services in medical care units, the development of medical care centres in Germany and a listing of the specific advantages and disadvantages of an MCU. This article focuses on the generally applicable facts and complements them with examples from general, visceral and vascular surgery. The main quantitative data on medical centre statistics come from different publications of the National Association of Statutory Health Insurance for Physicians. RESULTS: From a legal point of view the instrument MCU allows the participating of ambulatory and stationary care in the framework of medical care contracts. This has been especially extended for stationary applications, including the spectrum of possibilities that can contribute under certain circumstances for the provision of medical care in underdeveloped regions. Freelancers can benefit primarily from financial risk and minimising bureaucratic routine. The remuneration for services performed in the MCU is analogous to that of other ambulatory care providers. Basically, there are no disadvantages, but a greater design freedom and opportunities for the generation of aggregates are visible. The number of MCU in Germany has quadrupled in the last five years, indicating an establishment of an outpatient care landscape. MCU offers from the patient's perspective, providers and policy specific advantages and disadvantages. Indeed the benefits outweigh the disadvantages, but this is not yet verified by qualitative studies. CONCLUSION: The question of the appropriateness of medical care units as outpatient care instrumentation must be considered differentially. Under current conditions it appears suitable for ensuring the MCU and the supplement of care supply. Whether a value can be generated in the quality of care of patients, however, has to be examined separately, as there are no valid data so far. The same applies to economic assessments of costs and benefits from an economic perspective.

Closed claim review from a single carrier in New York: the real costs of malpractice in surgery and factors that determine outcomes.

INTRODUCTION: We postulated that a closed claim review of surgical cases would identify not only the quality of care elements but also factors that will predict successful legal outcomes. METHODS: One hundred eighty-seven closed surgical cases from a single carrier, which insured physicians practicing in 4 university hospitals in New York State, were reviewed, cataloged, and analyzed. RESULTS: Most suits occurred during midcareer and routine operations. Seventy-three percent of cases were won. The average payment and expenses per case were $220,846 ± $38,984 and $40,175 ± $4,204, respectively. Poor communication was identified in 24% of cases and was a predictor of a negative outcome (41% lost, P < .05), as was inadequate attending supervision (46% lost, P < .05). Expert reviews incriminated or exculpated physician defendants in 85 cases, which affected the outcome and cost. The quality of the physician defendant as a witness also affected the outcome. CONCLUSIONS: Most surgical malpractice claims are won. Although supervision, communication, and aggressive risk management are important, the use of quality experts and establishing credibility of the physician defendant are critical for successful legal outcome.

Developing business opportunities from concept to end point for craniofacial surgeons.

Craniofacial surgeons repair a wide variety of soft and hard tissues that produce the clinical expertise to recognize the need for an improved device or novel regenerative stem cell or use of molecules that may dramatically change the way clinical care for improved patient outcomes. The business pathway to bring a concept to clinical care requires knowledge, mentoring, and a team of experts in business and patent law.