Litigation in pediatric otorhinolaryngology: Lessons in improving patient care.

OBJECTIVE(S): Medico-legal claims involving children place a substantial financial burden on health services and have a profound emotional and psychological impact on clinicians. Our objective was to analyze both the common causes and cost of litigation in pediatric otorhinolaryngology. METHODS: A retrospective review of all clinical negligence claims within pediatric otolaryngology (0-17 years inclusive) in NHS (National Health Service) England held by the clinical negligence service 'NHS Resolution between' 4/2013 and 4/2020. RESULTS: There were 100 claims in pediatric otorhinolaryngology accounting for an estimated potential total cost of just under £49 million with an average of 14 claims per year. Over half (52%) of claims were related to an operation with cause codes "Operator Error/Intra-Op Problem", "Diathermy Injury" and "Failure to Warn - Consent" most cited. The most common operation cited in a claim was tonsillectomy with an average cost per claim of £47,084. There were 21 claims coded as either "failure to diagnose" or "failure to treat" in relation to cholesteatoma, with an average cost per claim of £61,086. CONCLUSION: This is the largest study to date analyzing the reasons and potential cost of clinical negligence claims within pediatric otolaryngology. Many learning opportunities exist to reduce patient morbidity, mortality and improve the patient experience through litigation data analysis.

Endoscopic Multipoint Laser System for Objective Pediatric Airway Assessment.

Recent technological advances within aeronautical engineering have demonstrated the delivery of objective quantitative endoscopic measurements to within one-hundredth of a millimeter. We sought to validate this emerging laser technology in a simulation-based assessment of pediatric airway stenosis. A 4.4-mm flexible endoscope, incorporating a laser measurement system projecting 49 laser points into the endoscopic view, was used to assess a simulated model of subglottic stenosis. Multiple anteroposterior and lateral measurements were obtained for each stenosis and compared with standard airway assessment techniques. Intra- and interobserver reliability was assessed. A total of 240 multipoint laser measurements were obtained of simulated airway stenosis. The mean difference from manual measurement was 0.1886 mm. The Bland-Altman plot showed low bias (0.011) and narrow 95% limits of agreement (-0.46 to 0.48). This advanced endoscopic measurement technique shows great promise for clinical development to benefit ongoing assessment and treatment of evolving pediatric airway stenosis.

Otorhinolaryngology litigation in England: 727 clinical negligence cases against the National Health Service.

INTRODUCTION: Litigation against the National Health Service (NHS) in England is rising. The aim of this study was to determine the incidence and characteristics of otorhinolaryngology clinical negligence claims in England. METHODS: A retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to otorhinolaryngology between April 2013 and April 2018. Analysis was performed using information for cause, patient injury and claim cost. Where claim information was adequately detailed, the authors categorised claims by subspecialty, diagnosis and surgery. RESULTS: A total number of 727 claims were identified with an estimated potential cost of £108 million. Out of these, 463 were closed claims. Including open claim reserves, the mean cost of a claim was £148 923. Head and neck surgery was the subspecialty with the highest number of claims (n = 313, 43%) and highest cost (£51.5 million) followed by otology (n = 171, £24.5 million) and rhinology (n = 171, £13.6 million). Over half of claims were associated with an operation (n = 429, 59%) where mastoid surgery (n = 46) and endoscopic sinus surgery (n = 46) were equally associated with the greatest number of claims. The most frequent causes for clinical negligence claims included failure or delay to diagnose (n = 178, 25%), failure or delay to treat (n = 136, 19%), intra-operative complications (n = 130, 18%) and failure of the consent process (n = 107, 15%). DISCUSSION: Clinical negligence claims in otorhinolaryngology are related to several different components of patient management and are not limited to postoperative complications. This study highlights the importance of robust pathways in out-patient diagnostics and the consenting process in order to deliver better patient care and reduce the impact of litigation. Keywords informed consent, malpractice, clinical negligence claims, litigation, otolaryngology.

Emergency medicine response to the COVID-19 pandemic in England: a phenomenological study.

BACKGROUND: The COVID-19 pandemic has stretched EDs globally, with many regions in England challenged by the number of COVID-19 presentations. In order to rapidly share learning to inform future practice, we undertook a thematic review of ED operational experience within England during the pandemic thus far. METHODS: A rapid phenomenological approach using semistructured telephone interviews with ED clinical leads from across England was undertaken between 16 and 22 April 2020. Participants were recruited through purposeful sampling with sample size determined by data saturation. Departments from a wide range of geographic distribution and COVID-19 experience were included. Themes were identified and included if they met one of three criteria: demonstrating a consistency of experience between EDs, demonstrating a conflict of approach between emergency departments or encapsulating a unique solution to a common barrier. RESULTS: Seven clinical leads from type 1 EDs were interviewed. Thematic redundancy was achieved by the sixth interview, and one further interview was performed to confirm. Themes emerged in five categories: departmental reconfiguration, clinical pathways, governance and communication, workforce and personal protective equipment. CONCLUSION: This paper summarises learning and innovation from a cross-section of EDs during the first UK wave of the COVID-19 pandemic. Common themes centred around the importance of flexibility when reacting to an ever-changing clinical challenge, clear leadership and robust methods of communication. Additionally, experience in managing winter pressures helped inform operational decisions, and ED staff demonstrated incredible resilience in demanding working conditions. Subsequent surges of COVID-19 infections may occur within a more challenging context with no guarantee that there will be an associated reduction in A&E attendance or cessation of elective activity. Future operational planning must therefore take this into consideration.

Pyogenic granuloma gravidarum: a case in the nasal cavity and the use of MRI as a preoperative surgical aide.

Pyogenic granuloma gravidarum is a benign fibrovascular proliferative lesion usually involving the oral gingivae in pregnant patients. While it also occurs, although less frequently, on other oral sites such as lips, tongue and palate, it is relatively unusual to find it in the nasal cavity. Furthermore, lesions normally involute spontaneously after childbirth. For persistent lesions requiring surgical management, imaging has historically been limited to CT. This case is notable not only for its uncommon location but also for its recurrent nature, failure to regress post partum and the use of MRI in the preoperative planning.