Supportive networks, healthier doctors and 'just culture': Managing the effects of medico-legal complaints on doctors.

BACKGROUND: When an error leads to possible patient harm and a complaint, the impact on doctors and patients can be profound. Doctors may respond in ways that risk harm to themselves, colleagues and patients, including withdrawing from peers, risk-avoidance practice and even suicidal ideation. OBJECTIVE: This article discusses current research and public discourse on the impact of complaints on doctors' personal and professional lives, as well as the way complaints and the fear of complaints affects doctors' clinical practice. It suggests strategies to ameliorate these effects before a complaint is made. DISCUSSION: When colleagues support one another and collectively reflect on their practice within a culture focused on patient safety, doctors facing complaints or presented with an error are less likely to isolate themselves and fear the worst. Using a common adverse event, the author discusses how analysing minor errors and near-misses can benefit patients, practitioners and practices.

Medicina defensiva: significado vs medición / Defensive medicine: meaning vs measurement

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Réplica de los autores a la carta: Medicina defensiva: significado vs medición / Reply: Defensive Medicine: meaning vs measurement

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Nuevas perspectivas en la resolución del error médico: National Health Service Resolution y CARe / New perspectives in resolving medical error: National Health Service Resolution and CARe

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Effect of Increasing Malpractice Insurance Cost and Subsequent Practice of Defensive Medicine on Out-of-Hospital Birth Rates in the United States.

BACKGROUND: Across the United States, the burden of malpractice litigation has influenced obstetricians and obstetric institutions to avoid high-risk patients, favor cesarean delivery, and decrease availability of trial of labor after cesarean. Recently, the United States has experienced an increase in out-of-hospital (OOH) births. OBJECTIVE: The main purpose of this article is to investigate the association between malpractice insurance premium (MIP) and OOH births in the United States from 2000 to 2014. STUDY DESIGN: We analyzed changes in OOH birth rates and MIP from 2000 to 2014 using birth data from the National Vital Statistics System and Medical Liability Monitor's annual survey, respectively. The change in OOH birth rates was then compared with the change in MIP. RESULTS: Between 2000 and 2014, there has been approximately 60% increase in MIP from national average of $40,949 to $65,210 (p < 0.05). OOH births increased 57% from 39,398 births to 59,674 births (p < 0.05). There was a significant positive correlation between increase in MIP and increase in OOH births (p < 0.05, R 2 = 0.14). CONCLUSION: MIP and OOH birth rates have a significantly associated increase from 2000 to 2014. Given that malpractice climate affects other aspects of obstetric practice, we cautiously propose that increasing MIP may be associated with an increase in OOH births.

Medicina defensiva en Atención Primaria / Defensive Medicine in Primary Care

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Medical errors, malpractice, and defensive medicine: an ill-fated triad.

For the first 180 years following the founding of the US, physicians occasionally were sued for medical malpractice. Allegations of negligence were errors of commission - i.e. the physician made a mistake by doing something wrong, usually mistreatment of a fracture or dislocation, a complication or death following a surgical procedure, prescribing the wrong medication, and after the discovery of the X-ray by Roentgen in 1895, causing radiation burns. In the mid twentieth century malpractice allegations slowly changed from errors of commission to errors of omission - i.e. the physician failed to do something right: almost always, failed to make a diagnosis. The number of malpractice lawsuits increased at a geometric rate beginning in the 1960s, and in the 1970s physicians began practicing defensive medicine, which lead physicians to order unnecessary radiology exams and tests. In the past 20 years the number of malpractice lawsuits has been decreasing, but the practice of defensive medicine has continued. Unnecessary exams and tests increase the likelihood of overdiagnosis and overtreatment, i.e. a new kind of error of commission.

Defensive Medicine Among Plastic and Aesthetic Surgeons in Israel.

BACKGROUND: Defensive medicine (DM) includes medical practices that are aimed at avoiding liability rather than benefitting the patient. DM has not been well characterized among plastic surgeons. OBJECTIVES: The authors examined the extents of intended and unintended DM among members of the Israeli Society of Plastic and Aesthetic Surgery (ISPAS) and identified risk factors for DM. METHODS: A total of 108 ISPAS members were asked to complete a questionnaire that addressed physician attitudes toward DM and intended or unintended DM practices. RESULTS: Seventy-eight surgeons (72.2% response rate) returned the questionnaire, although some questionnaires were returned incomplete. Forty respondents acknowledged practicing DM (ie, DM group), and 33 respondents did not (ie, non-DM group). There were no between-group differences in gender, years of practice, or number of previous litigations. Thirty-one percent of respondents in the DM group indicated that they avoid certain surgical procedures, compared with 6% of respondents in the non-DM group (P = .008). In private practice, 66.2% of respondents stated that they obtain written informed consent twice before surgery, and 100% request preoperative blood-coagulation testing. In contrast, 40% and 74% of respondents in public practice, respectively, acknowledged these behaviors (for consent, P = .027; for testing, P = .0059). Sixty-three percent of respondents prescribe antibiotics for more than 24 hours postoperatively, and this practice was slightly more common in the DM group (34 prescribe antibiotics vs 21 in the non-DM group; P = .079). CONCLUSIONS: DM is highly integrated into the daily medical practices of plastic surgeons in Israel.

Does defensive medicine change the behaviors of vascular surgeons? A qualitative review.

Although in literature few successful claims have been shown in comparison with other medical specialties such as gynaecology and orthopaedics, vascular surgery is included among high-risk specialties. The high-risk of receiving medical claims may lead vascular surgeons to practice defensive medicine, as is normal in several other areas of clinical practice. No studies are available to our knowledge of the incidence of defensive medicine in the field of vascular surgery. Taking into consideration the scarce amount of information, the authors provide a critical discussion regarding the application of defensive medicine behaviour among vascular surgeons.

¿En qué momento perdimos la cabeza? / When did we lose our heads?

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Defensa en profundidad para la evaluación de riesgos laborales por ruido en termoeléctrica / Deep defense to asses labor risks for noise in power station

INTRODUCCIÓN: Las técnicas de evaluación de riesgos laborales se llevan a cabo por diferentes procedimientos, a través de las aplicaciones de métodos normativos del cumplimiento de los parámetros asociados con las mediciones de los umbrales de daño a la salud del hombre. Sin embargo, no se tienen en cuenta los principios básicos de seguridad, que incluyen las experiencias de buenas prácticas en industrias de altos requisitos de seguridad y disponibilidad. OBJETIVOS: El objetivo de este artículo es proponer un método bajo el enfoque de defensa en profundidad para evaluar los riesgos laborales por ruido en la Central Termoeléctrica (CTE) de 100 MW. Material y MÉTODOS: Se aplicó la técnica de entrevistas a técnicos y especialistas en seguridad y salud del trabajo, así como tecnólogos para explorar los elementos que tomaban en cuenta en la evaluación de los riesgos laborales por ruido, y se realizó la consulta a especialistas para precisar los elementos que debían formar parte de los aspectos de seguridad de acuerdo al método propuesto. Además Se realizó la evaluación de los riesgos laborales por ruido de acuerdo a dos metodologías implementadas con anterioridad y la propuesta. RESULTADOS: Se muestran de acuerdo a las tres metodologías. Se determinó que la generación de ruidos no es un aspecto significativo a tener en cuenta, para la metodología 1, se evidenció una dispersión del nivel sonoro, con tendencia estable a los valores máximos en determinadas áreas según la Norma Cubana de ruido, para la metodología 2 mientras que para la metodología 3, los aspectos de seguridad evaluados negativamente por cada escalón, son los que se requieren tomar medidas correctivas dirigidas a modificar los ítems calificados negativamente a positivos para elevar el nivel de seguridad. CONCLUSIONES: La evaluación empleando escalones de defensa en profundidad aplicado a los riesgos laborales posibilita un análisis con el enfoque de procesos, que permite estimar la contribución relativa y sus causas, así como resolverlas en un corto plazo

The labour risks evaluation techniques are carried out using several methods, through the application of normative methods applying the execution of the parameters associated with the measurements of the men's health damage thresholds. Basic security principles are nevertheless not taken into account, which enclose the good practices experiences in high-requirement security and availability industries. OBJECTIVES: The purpose of this article is to propose a method attending on the defence in depth in order to evaluate the noise labour risks in the Thermal Power Station (TPS) of 100 MW. MATERIAL AND METHODS: In order to explore the elements considered in the evaluation of the noise labours risks, interviews to technicians and specialists in labour security and health were taken. It was carried out the consultation to specialists in order to specify the elements that should be part of the security aspects according to the nominative method. The evaluation of the labours risks for noise together with the proposal were also carried out according to two methodologies prior employed. RESULTS: three methodologies were used. It was determined that the noise generation is not a significant aspect to keep in mind for the methodology 1. For the methodology 2 it was demonstrated a dispersion of the noise level with stable tendency to the maximal values in determining areas according to the Noise Cuban Norm, while for the methodology 3, the security aspects negatively evaluated for each step, are those which require to take corrective measures implemented to modify the negatively-qualified items to positive in order to raise the security level. CONCLUSIONS: The evaluation using the depth security levels applied to the labour risks allows to estimate an analysis with the process approach, that allow not only to esteem the relative contribution and its causes but to resolve them in a short-term period

Informed consent and Italian physicians: change course or abandon ship--from formal authorization to a culture of sharing.

In Italy in recent years, an exponential increase in the frequency of medical malpractice claims relating to the issue of informed consent has substantially altered not only medical ethics, but medical practice as well. Total or partial lack of consent has become the cornerstone of many malpractice lawsuits, and continues to be one of the primary cudgels against defendant physicians in Italian courtrooms. Physicians have responded to the rising number of claims with an increase in 'defensive medicine' and a prevailing preoccupation with the purely formal aspects of consent. The result is a plethora of consent forms, believed to be a guarantee of 'informed consent', as well as a growing reliance on informed consent as a shield against judicial action brought by the patient. Physicians 'inform' patients without really sharing information, often delegating the task of communication to other professionals who are not doctors. Italian judges always condemn the physician when information to the patient has been inadequate, thus leading insurance companies to consider the lack of valid informed consent as the total responsibility of the physician and/or the hospital. It is necessary to change tack, to remove this idea of consent which permeates the defensive culture of medical practice. Italian physicians need to be trained, first of all, to become aware that information and consent are two distinct processes, albeit closely connected. Valid communication (in which there is information and consent) demands a higher level of professionalism from physicians.

Assessing the overuse of medicines.

The use of medicines has increased markedly in many countries over recent years, providing clear evidence of the increasing 'pharmacaeuticalisation' of society. This paper contributes to the sociological analysis of pharmaceuticalisation by starting to explore how we can begin to make judgements as to when and to what extent some medicines are being overused--an important aspect that, rather surprisingly, has not so far been the focus of attention those analysing the process. It considers the World Health Organisation's criteria for the 'rational' use of medicines, pointing to some of the issues they raise. It then develops a typology of over and underuse derived from these criteria. This provides a framework for the discussion of assessing overuse that focuses in particular on the widespread and increasing use of medicines that are not very effective for the conditions for which they are prescribed, and their use where the issue of clinical need is in doubt. Some of the factors that encourage overuse are also considered.

The effect of medical malpractice liability on rate of referrals received by specialist physicians.

Using nationally representative data from the United States, this paper analyzed the effect of a state's medical malpractice environment on referral visits received by specialist physicians. The analytic sample included 12,839 ambulatory visits to specialist care doctors in office-based settings in the United States during 2003­2007. Whether the patient was referred for the visit was examined for its association with the state's malpractice environment, assessed by the frequency and severity of paid medical malpractice claims, medical malpractice insurance premiums and an indicator for whether the state had a cap on non-economic damages. After accounting for potential confounders such as economic or professional incentives within practices, the analysis showed that statutory caps on non-economic damages of $250,000 were significantly associated with lower likelihood of a specialist receiving referrals, suggesting a potential impact of a state's medical malpractice environment on physicians' referral behavior.

Malpractice liability and defensive medicine: a national survey of neurosurgeons.

BACKGROUND: Concern over rising healthcare expenditures has led to increased scrutiny of medical practices. As medical liability and malpractice risk rise to crisis levels, the medical-legal environment has contributed to the practice of defensive medicine as practitioners attempt to mitigate liability risk. High-risk specialties, such as neurosurgery, are particularly affected and neurosurgeons have altered their practices to lessen medical-legal risk. We present the first national survey of American neurosurgeons' perceptions of malpractice liability and defensive medicine practices. METHODS: A validated, 51-question online-survey was sent to 3344 practicing U.S. neurosurgeon members of the American Association of Neurological Surgeons, which represents 76% of neurosurgeons in academic and private practices. RESULTS: A total of 1028 surveys were completed (31% response rate) by neurosurgeons representing diverse sub-specialty practices. Respondents engaged in defensive medicine practices by ordering additional imaging studies (72%), laboratory tests (67%), referring patients to consultants (66%), or prescribing medications (40%). Malpractice premiums were considered a "major or extreme" burden by 64% of respondents which resulted in 45% of respondents eliminating high-risk procedures from their practice due to liability concerns. CONCLUSIONS: Concerns and perceptions about medical liability lead practitioners to practice defensive medicine. As a result, diagnostic testing, consultations and imaging studies are ordered to satisfy a perceived legal risk, resulting in higher healthcare expenditures. To minimize malpractice risk, some neurosurgeons have eliminated high-risk procedures. Left unchecked, concerns over medical liability will further defensive medicine practices, limit patient access to care, and increase the cost of healthcare delivery in the United States.