Adverse events in carotid endarterectomy from a medicolegal perspective.

OBJECTIVES: Characterize factors raised in carotid endarterectomy litigation. METHODS: Outcomes, alleged causes of malpractice, and other factors were evaluated. RESULTS: Of the 37 verdicts and settlements, defendants were not liable in 25 (67.5%) cases. Frequently reported complications included stroke (51.3%) and hypoglossal nerve injury (27.0%), with other complications including airway compromise, vocal cord injury, and death. No cases reported myocardial infarction. Cerebral monitoring was mentioned in 2 cases, while inadequate informed consent, delayed diagnosis, and requirement of additional surgery were alleged in numerous instances. Settlements and jury awards averaged US$895 833 and US$1.53 million, respectively. CONCLUSIONS: Stroke and hypoglossal nerve injury are the most frequently litigated complications, and mean damages awarded were considerable. Knowledge of issues raised in our analysis may be included in a comprehensive consent process, potentially minimizing liability and improving patient safety.

In the eyes of the law: malpractice litigation in oculoplastic surgery.

PURPOSE: To assess characteristics associated with various outcomes of malpractice litigation, resulting from injuries sustained during oculoplastic procedures. METHODS: The Westlaw legal database (Thomson Reuters, New York, NY, U.S.A.) was used to obtain jury verdicts and settlements. Pertinent data were extracted from 69 malpractice cases litigated from 1988 to 2012 involving oculoplastic procedures, including alleged cause of malpractice, outcome, and defendant specialty. RESULTS: The most commonly litigated surgical procedures were blepharoplasty (63.8% of total) and brow lift surgery (11.6%). The most commonly alleged complications included excessive scarring (24.6%), lagophthalmos (24.6%), visual defects (23.2%), and exposure keratitis (21.7%). Plastic surgeons were the most commonly named defendants (46.4%), followed by both comprehensive ophthalmologists and fellowship-trained ophthalmic plastic surgeons (17.3% each). A defense verdict was held in 60.9% of cases, a plaintiff verdict in 31.9% of cases, and a settlement was reached in 7.2% of cases. Blindness, cranial nerve injury, and the allegation of a permanent deficit increased the likelihood of a case being resolved with payment to the plaintiff (Fisher exact tests, p < 0.05). CONCLUSIONS: Most litigated oculoplastic malpractice cases were resolved in favor of the defendant, while settlements and plaintiff decisions averaged $455,703. Blepharoplasty constituted two-thirds of cases, with the most frequently cited associated complications being unsightly scarring, lagophthalmos, and visual deficits. An alleged lack of informed consent (30.4%) or the need for additional surgery (39.1%) was present in a considerable proportion of cases, emphasizing the importance of a detailed informed consent and clear communication preoperatively regarding patient expectations.

Malodorous consequences: what comprises negligence in anosmia litigation?

BACKGROUND: Our objectives were to evaluate factors raised in malpractice litigation in which plaintiffs alleged that physician negligence led to olfactory dysfunction. METHODS: We analyzed publically available federal and court records using Westlaw, a widely used computerized legal database. Pertinent jury verdicts and settlements were comprehensively examined for alleged causes of malpractice (including procedures for iatrogenic causes), defendant specialty, patient demographics, and other factors raised in legal proceedings. RESULTS: Of 25 malpractice proceedings meeting inclusion criteria, 60.0% were resolved for the defendant, 12.0% were settled, and 28.0% had jury-awarded damages. Median payments were significant ($300,000 and $412,500 for settlements and awards, respectively). Otolaryngologists were the most frequently named defendants (68.0%), with the majority of iatrogenic cases (55.0%) related to rhinologic procedures. Associated medical events accompanying anosmia included dysgeusia, cerebrospinal fluid leaks, and meningitis. Other alleged factors included requiring additional surgery (80.0%), unnecessary procedures (47.4% of iatrogenic procedural cases), untimely diagnosis leading to anosmia (44.0%), inadequate informed consent (35.0%), dysgeusia (56.0%), and psychological sequelae (24.0%). CONCLUSION: Olfactory dysfunction can adversely affect quality of life and thus is a potential area for malpractice litigation. This is particularly true for iatrogenic causes of anosmia, especially following rhinologic procedures. Settlements and damages awarded were considerable, making an understanding of factors detailed in this analysis of paramount importance for the practicing otolaryngologist. This analysis reinforces the importance of explicitly including anosmia in a comprehensive informed consent process for any rhinologic procedure.

Malpractice in otology.

OBJECTIVE: (1) Analyze otologic procedural malpractice litigation in the United States of America. (2) Discuss ways to prevent future malpractice litigation. STUDY DESIGN AND SETTING: Case series with record review. METHODS: The study is a case series with review of court records pertaining to otologic procedures using the Westlaw legal database. The phrase medical malpractice was searched with terms related to otology and neurotology obtained from the AAO-HNS website. RESULTS: Of the 47 claims that met inclusion criteria, 63.8% were decided in the physician's favor, 25.5% were decided in the plaintiff's favor (average payment $446,697), and 10.6% were settled out of court (average payment $372,607). Cerumen removal was the most common procedure leading to complaint (21.3%) and the most likely procedure to lead to payment (50.0%). Hearing loss was the most common injury claimed among all cases (53.2%) and resulted in a high proportion of cases that led to payment (40.0%). Other common alleged injuries were facial nerve injury (27.7%), tympanic membrane perforation (23.4%), need for additional surgery (42.6%), and lack of informed consent (31.9%). In addition, cases resulting from acoustic neuroma or stapedectomy resulted in higher payments to the plaintiffs (average $3,498,597 and $2,733,000, respectively). CONCLUSIONS: Malpractice trials were resolved in the defendant's favor in the majority of cases. Cerumen removal was the most common procedure leading to complaint and the procedure most likely to result in payment. Hearing loss was the most common injury cited. Payment was highest in acoustic neuroma and stapedectomy cases.

Esophageal perforation and rupture: a comprehensive medicolegal examination of 59 jury verdicts and settlements.

BACKGROUND: Consequences accompanying esophageal perforation make this complication a prime litigation target. We characterize factors in jury verdicts and settlements regarding esophageal perforation, including operative procedure, patient demographics, alleged cause(s) of malpractice, outcome, and other factors. METHODS: Pertinent court records were examined for the aforementioned factors. RESULTS: Gastroenterologists, general surgeons, and anesthesiologists were the most commonly named defendants. Two thirds of outcomes were for the defendant, and 11.9 % were settled (median--$650,000); 20.3% resulted in awarded damages (median--$1.2 M). Esophagogastroduodenoscopy was the most commonly litigated procedure, followed by intubation and Nissen fundoplication. Necessity of repair, delayed diagnosis, death, and inadequate consent were the most frequently cited factors in litigation. CONCLUSIONS: An understanding of the factors important in determining legal responsibility is of great interest for practitioners in multiple specialties. The requirement of surgical repair and a delay in diagnosis are two of the most common factors present in litigated cases resulting in a payment. The importance of explicitly listing esophageal perforation in the informed consent for esophagogastroduodenoscopy, abdominal surgery, and any patients at risk of intubation injury needs to be emphasized.

Physician accountability in iatrogenic cerebrospinal fluid leak litigation.

BACKGROUND: The potentially severe complications resulting from cerebrospinal fluid (CSF) leak makes iatrogenic injury a medicolegal area of concern for otolaryngologists and neurosurgeons. The objectives of this analysis were to study legal outcomes as well as medical and nonmedical elements affecting malpractice litigation. METHODS: Public court records available in the Westlaw legal database (Thomson Reuters, New York, NY) were searched for medical malpractice litigation related to iatrogenic CSF leak. Of the 18 jury verdicts and settlements included, outcomes and awards, patient demographic data, and other factors instrumental in determining legal responsibility were recorded for comparison. RESULTS: Ten (55.6%) cases were resolved in the defendant's favor, 2 (11.1%) resulted in damages awarded by a jury, and 6 (33.3%) were settled out of court before resolution of trial. Mean damages awarded were $1.1 million, while out of court settlements averaged $966,887. Malpractice stemming from patients who underwent endoscopic sinus surgery comprised 77.8% of cases analyzed. The most frequent alleged factors cited for litigation included having to undergo additional surgery (88.9%), developing meningitis (50.0%), and failing to recognize complications in a timely manner (44.4%). Perceived deficits in informed consent were alleged in one-third of cases. CONCLUSION: Although a slight majority of cases were resolved in the defendant's favor, payments made were considerable, averaging approximately $1 million. Strategies to decrease liability and allow patients to make more informed decisions should include clear communication with patients that explicitly states potential risks, such as meningitis, and possible need to undergo additional reparative surgery.

Determination of legal responsibility in iatrogenic tracheal and laryngeal stenosis.

OBJECTIVES/HYPOTHESIS: Laryngotracheal stenosis usually occurs as a result of injury from endotracheal intubation or tracheostomy placement. With an estimated incidence of 1% to 22% after these procedures, chronic sequelae ranging from discomfort to devastating effects on quality of life, and even death, make this complication a potential litigation target. We examined federal and state court records for malpractice regarding laryngotracheal stenosis and examined characteristics influencing determination of liability. STUDY DESIGN: Retrospective analysis. METHODS: The Westlaw Next legal database (Thomson Reuters, New York, NY) was searched for pertinent federal and state malpractice cases and examined for several factors including alleged cause of malpractice, complications, case outcome, and specialty of the defendants. RESULTS: Twenty-three pertinent cases over 35 years were identified. Fourteen (60.9%) cases were decided in the physician's favor, with six plaintiff verdicts awarding an average of $922,129 for malpractice, and three out-of-court settlements averaging $441,600. Hospitals were the most frequently named defendants, and anesthesiologists were most commonly named physician defendants. Endotracheal intubations and tracheostomy history were frequent factors in these cases. Laryngeal lesions were more likely to result in payments, trending higher than those stemming from tracheal lesions. CONCLUSIONS: Multiple cases mentioned previous intubation as a potential risk factor that may have led to laryngotracheal stenosis. Location of stenosis and requirement of reparative procedures may also influence outcomes. Cases not decided in the defendant's favor frequently included other extenuating circumstances, including severity of other injuries. Although the majority of cases were defendant decisions, the verdicts decided for the plaintiffs had considerable damages awarded.

Legal liability in iatrogenic orbital injury.

OBJECTIVES/HYPOTHESIS: In this study, we detailed factors governing legal outcomes in iatrogenic orbital injury, with the purpose of discussing strategies to minimize liability and enhance patient safety. STUDY DESIGN: Retrospective analysis. METHODS: Jury verdict and settlement reports were searched from publically available federal and state court records using the Westlaw database (Thomson Reuters, New York, NY). After exclusion of nonrelevant cases, 20 cases of iatrogenic orbital injuries were examined for factors such as legal outcome, damages awarded, defendant specialty, alleged causes of malpractice, and patient demographic information. RESULTS: The majority (60.0%) of cases were resolved in the defendant's favor. Payment was considerable for the cases decided in support of the plaintiff, averaging $1.13 million. Out-of-court settlements averaged $1.78 million (range, $487,500-$3.9 million), whereas jury-awarded damages averaged $472,661 (range, $75,000-$763,214). Complications stemming from endoscopic sinus surgery were most common (50.0%). Diplopia was the most common medical complaint (50.0%), whereas permanent deficits and having to undergo additional surgery were each present in 65.0% of cases. CONCLUSIONS: The potential for permanent sequelae of iatrogenic orbital injury makes this complication susceptible to malpractice litigation. Otolaryngologists were the most common defendants. Although cases were resolved in the defendant's favor 60% of the time, payments made were considerable, averaging $1.13 million. Steps to minimize liability and improve patient safety include an informed consent process explicitly listing risks, including diplopia and blindness, and obtaining timely ophthalmology consultation when a complication is recognized.

Characterizing liability for cranial nerve injuries: a detailed analysis of 209 malpractice trials.

OBJECTIVES/HYPOTHESIS: The potential for adverse events with lasting functional effects makes cranial nerve (CN) injury a target for litigation. Our objective was to comprehensively examine records of malpractice trials and detail issues influencing outcomes. STUDY DESIGN: Retrospective analysis. METHODS: The Westlaw database (Thomson Reuters, New York, NY) was searched for jury verdict reports related to medical malpractice and CN injury. After excluding nonrelevant cases, we examined 209 trials for characteristics including nerve(s) injured, alleged causes of malpractice, demographic information, specialty, and outcome. RESULTS: The most commonly litigated CNs were VII (24.4%) and II (19.6%). Sixty-nine (33.0%) trials resulted in damages awarded. Outcomes varied, ranging from a 29.2% plaintiff success rate for CN XI injury to 48.4% for CN II injury. Plaintiffs had less success with increasing age. Average damages awarded were $1.7 million. The most commonly named defendants were otolaryngologists and general surgeons. Individual considerations varied but commonly included alleged deficits in informed consent (25.4%), unnecessary procedures (14.8%), undergoing additional surgery (25.8%), and untimely recognition of complications (23.9%). CONCLUSIONS: Malpractice trials were resolved in the defendant's favor the majority of the time. In cases where plaintiffs were successful, however, awards were considerable, averaging nearly $2 million. Factors influencing case outcome included age, location, perceived deficits in informed consent, allegedly unnecessary surgery, requiring additional surgery to repair a complication, and untimely recognition of complications. Although specific factors should be taken into consideration with each procedure, providing detailed informed consent and communicating with patients regarding expectations may minimize liability.

Determining legal responsibility in otolaryngology: a review of 44 trials since 2008.

PURPOSE: Medicolegal factors contribute to increasing healthcare costs through the direct costs of malpractice litigation, malpractice insurance premiums, and defensive medicine. Malpractice litigation trends are constantly changing as a result of technological innovations and changes in laws. In this study, we examine the most recent legal decisions related to Otolaryngology and characterize the factors responsible for determining legal responsibility. METHODS: The Westlaw legal database (Thomson Reuters, New York, NY) was used to search for jury verdicts since 2008 in Otolaryngology malpractice cases. The 44 cases included in this analysis were studied to determine the procedures most commonly litigated and progressing to trial, as well as the year, location, alleged cause of malpractice, specialty of co-defendants, and case outcomes. RESULTS: Out of the 44 cases included in this analysis, physicians were not found liable in 36 (81.8%) cases. Rhinologic procedures comprised 38.6% of cases litigated, and rulings were in physicians' favor in 66.7% of endoscopic sinus surgery (ESS) cases and all non-ESS rhinologic cases. A perceived lack of informed consent was noted in 34.1% of cases. The 8 jury awards averaged $940,000 (range, $148,000-$3,600,000). CONCLUSION: Otolaryngologists were not found liable in the majority of cases reviewed. Rhinologic surgeries were the most common procedures resulting in litigation. Adenotonsillectomies, thyroidectomies, and airway management are also well-represented. Perceived deficits in informed consent and misdiagnosis were noted in a considerable proportion of otolaryngologic malpractice cases resulting in jury decisions.

From the operating room to the courtroom: a comprehensive characterization of litigation related to facial plastic surgery procedures.

OBJECTIVES/HYPOTHESIS: Malpractice litigation has increased in recent decades, contributing to higher health-care costs. Characterization of complications leading to litigation is of special interest to practitioners of facial plastic surgery procedures because of the higher proportion of elective cases relative to other subspecialties. In this analysis, we comprehensively examine malpractice litigation in facial plastic surgery procedures and characterize factors important in determining legal responsibility, as this information may be of great interest and use to practitioners in several specialties. STUDY DESIGN: Retrospective analysis. METHODS: The Westlaw legal database was examined for court records pertaining to facial plastic surgery procedures. The term "medical malpractice" was searched in combination with numerous procedures obtained from the American Academy of Facial Plastic and Reconstructive Surgery website. RESULTS: Of the 88 cases included, 62.5% were decided in the physician's favor, 9.1% were resolved with an out-of-court settlement, and 28.4% ended in a jury awarding damages for malpractice. The mean settlement was $577,437 and mean jury award was $352,341. The most litigated procedures were blepharoplasties and rhinoplasties. Alleged lack of informed consent was noted in 38.6% of cases; other common complaints were excessive scarring/disfigurement, functional considerations, and postoperative pain. CONCLUSIONS: This analysis characterized factors in determining legal responsibility in facial plastic surgery cases. Several factors were identified as potential targets for minimizing liability. Informed consent was the most reported entity in these malpractice suits. This finding emphasizes the importance of open communication between physicians and their patients regarding expectations as well as documentation of specific risks, benefits, and alternatives.