Liability of Health Professionals Using Sensors, Telemedicine and Artificial Intelligence for Remote Healthcare.

In the last few decades, there has been an ongoing transformation of our healthcare system with larger use of sensors for remote care and artificial intelligence (AI) tools. In particular, sensors improved by new algorithms with learning capabilities have proven their value for better patient care. Sensors and AI systems are no longer only non-autonomous devices such as the ones used in radiology or surgical robots; there are novel tools with a certain degree of autonomy aiming to largely modulate the medical decision. Thus, there will be situations in which the doctor is the one making the decision and has the final say and other cases in which the doctor might only apply the decision presented by the autonomous device. As those are two hugely different situations, they should not be treated the same way, and different liability rules should apply. Despite a real interest in the promise of sensors and AI in medicine, doctors and patients are reluctant to use it. One important reason is a lack clear definition of liability. Nobody wants to be at fault, or even prosecuted, because they followed the advice from an AI system, notably when it has not been perfectly adapted to a specific patient. Fears are present even with simple sensors and AI use, such as during telemedicine visits based on very useful, clinically pertinent sensors; with the risk of missing an important parameter; and, of course, when AI appears "intelligent", potentially replacing the doctors' judgment. This paper aims to provide an overview of the liability of the health professional in the context of the use of sensors and AI tools in remote healthcare, analyzing four regimes: the contract-based approach, the approach based on breach of duty to inform, the fault-based approach, and the approach related to the good itself. We will also discuss future challenges and opportunities in the promising domain of sensors and AI use in medicine.

Predictors of Defensive Practices among Italian Psychiatrists: Additional Findings from a National Survey.

Background: Defensive medicine is characterized by medical decisions made primarily as a precaution against potential malpractice claims. For psychiatrists, professional responsibility encompasses not only the appropriateness of diagnosis and treatment but also the effects of their interventions on patients and their behaviors. Objective: To investigate the socio-demographic, educational, and occupational characteristics and work-related attitudes that may serve as predictors of defensive medicine among Italian psychiatrists. This research extends the results of a previous analysis based on a national survey. Methods: A secondary analysis of the database of a national survey on attitudes and behaviors of Italian psychiatrists regarding defensive medicine and professional liability was performed for this study. Results: Among 254 surveyed psychiatrists, 153 admitted to practicing defensive medicine, while 101 had this attitude with less than half of their patients. The first group was predominantly comprised of women (p = 0.014), who were younger in age (43.34 y 9.89 vs. 48.81 y 11.66, p < 0.001) and had fewer years of professional experience (12.09 y ± 9.8 vs. 17.46 y ± 11.2, p < 0.001). There were no significant differences in prior involvement in complaints (p = 0.876) or the usual place of work (p = 0.818). The most prominent predictors for practicing defensive medicine were (1) considering guidelines and good clinical practices not only for their clinical efficacy but also or exclusively for reducing the risk of legal complaints for professional liability (OR = 3.62; 95%CI, 1.75-7.49), and (2) hospitalizing patients with violent intentions even if not warranted according to their mental state (OR = 2.28; 95%CI, 1.50-3.46, p < 0.001). Prioritizing protection from professional liability over patients' actual needs in prescribing or adjusting drug dosages and in involuntary hospitalization, as well as prescribing lower dosages than recommended for pregnant patients, were identified as additional predictors. Finally, years of professional experience exhibited a protective function against defensive practices. Conclusions: Psychiatrists advocate the need to implement a 'risk management culture' and the provision of more balanced duties in order to ensure ethical and evidence-based care to their patients. A particular source of concern stems from their professional responsibility towards not only the health of patients but also their behavior. However, these aspects conflict with a limited potential for assessment and intervention based on effective clinical tools. A reform of professional liability that considers the specificities of patients cared for by mental health services could contribute to reducing the risk of defensive medicine.

Practices, organisation, and regulatory aspects in advising on antibiotic prescription: the international ESCMID AntibioLegalMap survey.

PURPOSE: Giving advice about antibiotic prescription through dedicated consultations is a cornerstone of antibiotic stewardship programmes. Our objective was to explore practices, organisation, and regulatory requirements related to antibiotic advising. METHODS: We performed an international, exploratory, Internet-based, cross-sectional survey targeting infectious diseases and clinical microbiology specialists. It was disseminated through ESCMID and ESGAP networks. RESULTS: Answers from 830 participants (74 countries, 77% of participants from Europe) were collected. Consultations were mostly given on demand (81%, 619/764), while unsolicited consultations targeting specific conditions (e.g., positive blood culture) were less frequent (66%, 501/764). Consultations usually included indications on diagnostic work-up and follow-up (> 79%). Curbside consultations (i.e., without examining the patient) were reported by 82% (598/733) of respondents, mainly by phone (89%, 531/598). The referring physician was considered authorised not to follow the advice by 57% (383/676). Direct consultations (i.e., after examining the patient) were recorded in the medical file more frequently than curbside consultations (69%, 472/689 vs 35%, 206/592). Concerning legal liability, the majority of respondents considered that it is shared between the adviser and the referring physician, who, however, is considered primarily responsible. The advisers' liability was considered to be lower in cases of curbside and unrecorded consultations. Significant inter-countries and intra-country variability were identified, suggesting that the setting markedly influenced practices. CONCLUSION: Significant variability exists in the practice of antibiotic advising. This concerns both the organisation of care and how advisers perceive regulatory requirements. These elements must be taken into account when implementing antibiotic stewardship programmes and when training stewards.

The contribution of legal medicine in clinical risk management.

BACKGROUND: In advanced health services, a main objective is to promote the culture of safety and clinical risk management. In this regard, the reporting of sentinel events fits within a perspective of error analysis, attempting to propose solutions aimed at preventing a new occurrence of the harmful event. The purpose of this study is to analyze the contribution of medico-legal litigation in the management of clinical risk and to propose an organizational model so as to coordinate the intervention of clinical risk management and medico-legal services. METHODS: Retrospective review of 206 cases of medico-legal litigation, settled against a Hospital of a North-eastern city in Italy from January 1, 2014 and December 31, 2015. RESULTS: Approximately 20% of cases, that are classifiable as "sentinel events", were not reported due to various factors. The reason that these events are under-reported is mainly due to the latency between the event itself and its manifestation as a serious damage to health as well as the discomfort in reporting the events of this kind, which is still widespread among healthcare workers. The systematic research of the available documentation for medico-legal purposes permits the acquisition of more information concerning the clinical event, thereby increasing the number and accuracy of the reports to the clinical risk unit. CONCLUSION: The analysis of medico-legal litigation is a valid tool to enhance the reporting of "sentinel events". One possible proposal is the implementation of an organizational model to establish a rapid procedure for the reporting of sentinel events during the evaluation of medico-legal litigations.

A technological advance for 21st century obstetricians: the electronically-controlled vacuum extractor.

OBJECTIVE: To describe an innovative electronically-controlled vacuum extractor (VE) in detail and to illustrate its performance characteristics, as observed in a laboratory study. DESIGN: Thirty simulated, vacuum-assisted deliveries. MAIN OUTCOME MEASURE(S): (1) The ability to measure in real-time of the pull applied and to sound an alert, when the traction approaches the negative pressure under the cup, to prevent its detachment. (2) The recording and printing of a graphic representation of the pull applied (vacuum delivery graph). (3) The emission of a warning signal when the 15-min time limit of continuous cup application on the fetal scalp, is reached. RESULTS: No cup detachment occurred in any of the 15 vacuum-assisted deliveries, in which traction was kept below the adhesive force of the cup [44 lb (20 kg)], except in three cases, due to loss of negative pressure. In the remaining 15 tests, in which traction was greater than the adhesive force of the cup, "pull-offs" inevitably occurred. Furthermore, upon reaching the 15-min time limit of continuous cup application on the fetal cephalic model, a warning signal was emitted, as programmed. Conclusions We demonstrated that the electronically-controlled VE, with its distinctive pull-sensing handle, performs suitably for its intended purposes. The ability of the modernized device to decrease the incidence of cup detachment, secondary to the inadvertent application of excessive traction, may result in considerable safety, medico-legal and didactic advantages.

The quality of upper extremity orthopedic care in liability claims filed and claims paid.

PURPOSE: To review a series of closed liability claims for upper extremity conditions to guide improvements for upper extremity care and thereby reduce the frequency of paid claims. METHODS: The authors, a team of 3 orthopedic surgeons and 3 nonphysician investigators experienced in closed claims research, investigated 108 closed upper extremity liability claims from a large United States-wide insurer for events that occurred between 1996 and 2009. We sought to determine the types of conditions, treatments, and surgeon factors common to claims made and claims paid. RESULTS: Liability claims were primarily for the care of common problems, such as fractures (n = 52; 48%) or degenerative conditions (n = 24; 26%), rather than complex challenging conditions or disorders, such as deficiencies treated with replantations or tissue transfers. The most common adverse outcomes in these claims were nonunion or malunion of fractures (n = 29; 27%), nerve injury (n = 20; 19%), and infection (n = 13; 12%). Most claims (n = 57; 53%) involved a permanent injury. The surgeon's operative skills were more commonly an issue in paid claims (n = 13; 45%) than in claims without payment (n = 14; 19%). Claims for mismanagement of fractures (n = 52; 48% of all claims) were more likely to result in payment (n = 20; 38%) than nonfracture claims (n = 10; 18%). CONCLUSIONS: This analysis suggests that the incidence of upper extremity claims made and claims paid may be reduced if surgeons acquire and maintain the knowledge and skills necessary for the care of the common conditions they encounter, including fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

The legislative position of the Osteopath in Italy after the Decree of the Ministry of Universities and Research of 29 November 2023, in agreement with the Minister of Health: implications in terms of professional responsibility and current shortcomings.

Background: At the end of a long definition and legislative process (Law No.3 of 11 January 2018 and DPR No 131 of 2021), started under the thrust of the European directives, with the Decree of the Ministry of Universities and Research of 29 November 2023, in agreement with the Minister of Health, osteopathy in Italy has become a healthcare profession in all respects. Materials and Methods: In order to understand the current legislative and professional position of the Osteopath, research of the original definitions and the history of the profession has been carried out, assessing an overview of the current situations among EU countries. Therefore, an analysis of the current Italian legislation has been carried out in a medical-legal key, with a critical eye aimed above all at assessing the current shortcomings. Conclusions: The inclusion of osteopathy as a healthcare profession in Italy is a significant step towards the regulation and recognition of this practice, implying considerable innovations both in terms of access to the profession, both in the field of the professional health responsibility. Even if with the Decree of 29 November 2023, a significant step forward has been made, further regulatory and control measures are needed to ensure the quality, safety, and effectiveness of osteopathic treatments, as well as the protection of patients and the professionalism of operators.

Analysis of Closed Claims Among All Medical Specialties: Importance of Communication and Other Non-Clinical Contributing Factors.

Objective: Medical malpractice claims represent patient dissatisfaction of care delivered by their healthcare provider. Evaluation of contributing factors (CFs) associated with claims provides important information to optimize the patient-provider relationship. Study Design: A total of 21,101 closed claims with 54,479 CFs (2.2 contributing factors per claim) from a large medical professional liability coverage provider were analyzed from 2010 to 2019. Results: Four clinical CFs (technical performance, management of therapy, patient assessment, and patient factors) and four nonclinical CFs (communication between providers and patient, communication among providers, failure or delay in obtaining a consult, and insufficient documentation) were identified >1,500 times. Nonclinical CFs increased as a percentage from 50% in the first part of the study period to 54% in the second part of the study period (p < 0.01), and were more frequent in cases associated with indemnity when compared to clinical CFs (Nonclinical: 57% vs 43%; p < 0.001). Poor communication as a CF increased steadily during the study period (3-year average; 2010-2012: 777 CF/year vs 2017-2019: 1207 CF/year; p < 0.001). In claims associated with high severity injury, poor communication among providers was more significant than poor communication between the provider and patient (63% vs 29%; p < 0.001), mainly due to failure to convey the severity of the patient's condition. For non-surgical specialties except psychiatry, communication was the highest CF and the second or third CF for psychiatry or surgical specialties. Discussion: Clinical and nonclinical CFs are equally important for malpractice claims. Communications issues are particularly important regardless of specialty. While focusing on clinical quality is important, implementing strategies that account for nonclinical issues, with a particular focus on communication, would have significant benefits particularly in an environment of increased consolidation of healthcare delivery systems.

Council Directive 2013/59/Euratom of 5 December 2013 laying down basic safety standards for protection against the dangers arising from exposure to ionising radiation: medico-legal and legal-comparative study.

Abstract: This paper is a scientific contribution on basic safety standards, related to protection against hazards arising from exposure to ionizing radiation: medico-legal issues resulting from the research of the University of Campania and the study conducted by the Italian Society of Medical and Interventional Radiology are reported.

Investigation on physical restraint use in hospital: health responsibility, ethical and medical legal considerations.

Background: The issue of restraint has long been considered a difficult political and social situation, affecting both healthcare wor-kers and facilities. The practice of restraint is still widespread in many public and private care settings, but there is a lack of systemic studies capable of monitoring the phenomenon. The framing of the question essentially concerns the right to personal freedom, guaranteed by the Italian Constitution. Materials and Methods: An anonymous questionnaire was developed containing questions on knowledge of the regulations on restraints, how, ways, and when they are implemented, and general information such as age, gender, educational qualification, qualification, O.Us. to which they belong. The collected data were statistically processed (Chi-square test) with the Epi Info 7.1.5 program (CDC-Atlanta- USA). A total of 1002 questionnaires were completed. The stratification of the sample by structure shows that 73.9% were public facilities. The indicative figure is represented by the 23.8% of respondents who say that "the restraint is not noted in the medical record". Conclusions: Restraint could be a real risk for the healthcare worker, encroaching on the issue of health liability. It is therefore important to raise awareness among healthcare professionals and top management of the need to structure, at company level, procedures that comply with the "Recommendations on physical restraint" to overcome the use of restraint through the improvement of care pathways in compliance with organizational and risk management standards.

Artificial intelligence in healthcare: an Italian perspective on ethical and medico-legal implications.

Artificial intelligence (AI) is a multidisciplinary field intersecting computer science, cognitive science, and other disciplines, able to address the creation of systems that perform tasks generally requiring human intelligence. It consists of algorithms and computational methods that allow machines to learn from data, make decisions, and perform complex tasks, aiming to develop an intelligent system that can work independently or collaboratively with humans. Since AI technologies may help physicians in life-threatening disease prevention and diagnosis and make treatment smart and more targeted, they are spreading in health services. Indeed, humans and machines have unique strengths and weaknesses and can complement each other in providing and optimizing healthcare. However, the healthcare implementation of these technologies is related to emerging ethical and deontological issues regarding the fearsome reduction of doctors' decision-making autonomy and acting discretion, generally strongly conditioned by cognitive elements concerning the specific clinical case. Moreover, this new operational dimension also modifies the usual allocation system of responsibilities in case of adverse events due to healthcare malpractice, thus probably imposing a redefinition of the established medico-legal assessment criteria of medical professional liability. This article outlines the new challenges arising from AI healthcare integration and the possible ways to overcome them, with a focus on Italian legal framework. In this evolving and transitional context emerges the need to balance the human dimension with the artificial one, without mutual exclusion, for a new concept of medicine "with" machines and not "of" machines.

Evaluation of insurance policies in the Saudi Arabian construction contracts.

The construction sector is more complicated and prone to risk than many other industries due to the size of the projects and the financial capital involved. Arranging insurance is the prudent course of action for risk management in the construction sector. There is a lack of clarity in insurance policies for public construction projects in the Kingdom of Saudi Arabia (KSA), which poses additional risks to all involved contracting parties. The aim of this research is to evaluate insurance policies in the KSA's public construction projects to identify the key deficiencies and obstacles and provide a road map for improvement in the insurance sector concerning insurance against financial losses, professional liability, defects' liability, hidden defects, and others. Forty-two contractors and forty-two owners in Saudi Arabia were surveyed, using a questionnaire to gather information for the study about their knowledge of and attitudes regarding risk transfer through insurance (professional liability, defects liability, and hidden defects). The study also covers the selection criteria for insurance policies for projects that potentially shift risk to the construction sector. Ten criteria were also examined as potential sources of liability issues and suggested as potential remedies in KSA. The findings indicate that the duty and liability of engineers and those participating in these projects can be offset by engineers' insurance against professional errors and hidden flaws, and by the construction industry's clear liability policy. Additionally, the research is envisaged to contribute to construction projects' overall quality and safety, ensuring that robust legal and financial safeguards protect all stakeholders.

Beyond the distance between juridic and scientific decision-making process: An evidence-based prediction algorithm for professional liability assessment in healthcare-associated infections.

BACKGROUND: HAIs (Healthcare-Acquired-Infections) have been recently the subject of judgment n. 6386 pronounced on 3rd March 2023 by the Italian Supreme Court. This sentence provided three criteria to determine whether a health facility is responsible for the patient contracting a nosocomial infection, i.e. time criterion, topographical criterion and clinical criterion. Accordingly, the healthcare facility is obliged to prove the fulfillment of a series of preventive hygiene measures specifically detailed by the legislator. Herein, the positive predictive value of these criteria ("juridic criteria") in the identification of professional liability for nosocomial infections was evaluated in comparison with clinical criteria reviewed by Infectious Disease specialists ("Infectious-Disease criteria", i.e. presence of a Multidrug Resistant Organism (MDRO); development of surgical site infection; inadequate antibiotic therapy; inadequate disinfection). METHODS: Two retrospective cohorts were compared from the Portal of Telematic Services of the Ministry of Justice; 51 patients were extrapolated from Italian judgments concerning claims for Gram-negative nosocomial infections in the three-year period 2020-2022. On the other side, from the electronic database of University Hospital of Bari we extracted 349 patients affected by Gram-negative infections in the same timespan. Both "juridic" criteria and "Infectious-Disease" criteria were then applied to the full cohort after stratification for cohort of origin and after stratification for nosocomial or non-nosocomial infections. Predictive value of criteria was evaluated through receiver operating characteristic (ROC) curves and area under the curve (AUC). RESULTS: Overall, the incidence of definite nosocomial infections (according to final judgement or clinical records discharge letter) was 84 % in juridic cohort and 46 % in "real-world" series. Data suggested that the presence of all three juridic criteria [ROC AUC = 0.944 (95%CI = 0.924-0.963)] or the four clinical criteria [ROC AUC = 0.948 (95%CI = 0.928-0.969)] predicted well a case of nosocomial infection with professional liability. Moreover, by summarizing both criteria in a single classification system, the generated ROC curve (was the one with the highest AUC [0.9488 (95%CI = 0.928-0.969)]. Accordingly, further tests were performed, evaluating the predictive value of one juridic criterium plus at one of more Infectious-Disease criteria. Interestingly, the ROCs curves demonstrated that the presence of at least 1 juridic criteria plus at least 2 Infectious Disease criteria reached a predictive value comparable to 2 or 3 juridic criteria. CONCLUSIONS: The results highlight the efficiency of new criteria laid down in the judgment of the Italian Supreme Court to attribute liability for nosocomial infection despite the disputed distance between juridic and scientific decision-making process. In addition, the use of a combined score combining "juridic" and "Infectious-Disease" criteria provides a high-quality tool to be used by technical consultants to make up for lack of clinical documentation by passing judgments concerning litigation about professional liability in case of nosocomial infections. This sheds light on the possibility to face worldwide judicial inquiries with scientific rigor.

Legal Issues 101: Malpractice and Licensure Discipline.

This article is part of a series of articles titled "Legal Issues 101." The purpose of this series is to address common questions and misconceptions regarding the law and school health. Nurses frequently conflate malpractice or negligence with professional licensure discipline and it is important to understand the difference. To reduce liability exposure, school nurses must understand what their risks are and what they are not, for both civil lawsuits and for nursing board discipline.

Medical Professional Liability in Obstetrics and Gynecology: A Pilot Study of Criminal Proceedings in the Public Prosecutor's Office at the Court of Rome.

Criminal trials and claims against physicians for malpractice-related damages have increased dramatically in recent years, and, with Obstetrics and Gynecology being one of the medical specialties that is at the highest risk, we carried out a retrospective analysis aimed at examining all Obstetrics- and Gynecology-related medical professional liability prosecutions within the General Register of Criminal Records of the Rome Public Prosecutor's Office between the years 2000 and 2014. The number of prosecutions increased steadily in the years 2000-2005, with varying trends in the following years. A total of 727 healthcare professionals were involved in criminal charges, and most prosecuted crimes were related to Articles 590 and 589 of the Italian Penal Code, followed by violations of Article 17 of Law 194/78. In most cases, filing was requested and granted without opposition. In 95 cases, an expert witness was appointed by the Court, and in 68 cases, the technical consultants of the State Prosecutor found culpable conduct. Public hospitals, private nursing homes and outpatient clinics, or private practices were mostly involved; in 45% of the cases, the physicians were hospital employees. In this setting, Italy is prepared to introduce new measures and regulations to address the issues posed by defensive medicine and charges of professional liability for healthcare providers.

AI and professional liability assessment in healthcare. A revolution in legal medicine?

The adoption of advanced artificial intelligence (AI) systems in healthcare is transforming the healthcare-delivery landscape. Artificial intelligence may enhance patient safety and improve healthcare outcomes, but it presents notable ethical and legal dilemmas. Moreover, as AI streamlines the analysis of the multitude of factors relevant to malpractice claims, including informed consent, adherence to standards of care, and causation, the evaluation of professional liability might also benefit from its use. Beginning with an analysis of the basic steps in assessing professional liability, this article examines the potential new medical-legal issues that an expert witness may encounter when analyzing malpractice cases and the potential integration of AI in this context. These changes related to the use of integrated AI, will necessitate efforts on the part of judges, experts, and clinicians, and may require new legislative regulations. A new expert witness will be likely necessary in the evaluation of professional liability cases. On the one hand, artificial intelligence will support the expert witness; however, on the other hand, it will introduce specific elements into the activities of healthcare workers. These elements will necessitate an expert witness with a specialized cultural background. Examining the steps of professional liability assessment indicates that the likely path for AI in legal medicine involves its role as a collaborative and integrated tool. The combination of AI with human judgment in these assessments can enhance comprehensiveness and fairness. However, it is imperative to adopt a cautious and balanced approach to prevent complete automation in this field.

The Power of Customized Clear Aligners in Closing Molar Edentulous Spaces: Clinical and Medico-Legal Considerations in a Scoping Review and Case Report.

Successful closure of edentulous spaces with clear aligners (CAs) is influenced by many factors. CAs are tailored orthodontic devices whose predictability may have relevant medico-legal implications. This study presents a scoping review about missing molar space closure (MMSC) with CAs and a clinical case. This study aims to highlight the feasibility of molar space closure by mesialization with CAs without hybrid supports. Following PRISMA Sc-review guidelines, English-written randomized/non-randomized/observational clinical studies on PubMed, Scopus, Cochrane and Lilacs were searched. An 18-year-old patient, with upper and lower edentulous spaces due to the loss of two first molars, was rehabilitated with CAs (Sorridi®, Sorridi srl, Latina, Italy) without hybrid supports and attachments. The therapy was carried out over 10 months. Currently, there are no studies documenting MMSC by mesialization with only CAs. Existing articles document the closure of premolar or incisor spaces. The upper and lower left second molars replaced the missing first molars, and erupting third molars replaced adjacent teeth. The biomechanical effects in space closure with CAs related to extraction cases appear as priorities of clinical/medico-legal interest. Our case turns attention to this movement of CAs without attachments/hybrid supports, indicating that even such a complex treatment can be comfortable for patients and safely predictable for specialists.

Healthcare-acquired Sars-Cov-2 infection: A viable legal category?

In the context of the Sars-Cov-2 pandemic, according to the various periods of emergency and the rate of infections, hospitalized subjects also contracted the infection within the ward, sometimes with the development of disease (COVID-19) and sometimes with permanent damage. The authors wondered if Sars-Cov-2 infection should be considered on a par with other infections acquired in the healthcare setting. The non-diversified diffusion between the health and non-health sectors, the ubiquity of the virus and the high contagiousness, together with the factual inability to prevent it by the health structures, despite the adoption of entry control, practices of isolation of positive subjects, and staff surveillance, lead to consider COVID-19 in a different way, in order to otherwise burden health structures in the face of unmanageable risks, clearly also dependent on exogenous and uncontrollable factors. The guarantee of care safety must, in the pandemic, be able to compare with the real capacity for intervention according to the asset of the current health service, requesting State intervention with alternative instruments, such as una tantum compensation, for COVID-19 damage reparation occurred in the health sector.

Vox clamantis in deserto: a survey among Italian psychiatrists on defensive medicine and professional liability.

Due to recent events, professional liability for psychiatrists in Italy is currently a matter of lively debate. Specifically, overwhelming pressure on psychiatrists' duties has been brought by regulatory developments, such as the closure of forensic psychiatric hospitals, with the consequent return of offenders to community-based care, and the mental health consequences of the pandemic. According to Italian courts, psychiatrists are not only responsible for diagnostic and therapeutic appropriateness but also for the effects of their interventions on patients, and their behaviors. The aim of this study was to explore the attitude and behaviors of Italian psychiatrists regarding defensive medicine and professional liability. A total sample of 254 psychiatrists was surveyed by means of a quantitative online questionnaire. Most psychiatrists reported practicing defensive medicine (no. 153/254, 60.2%) and felt that their position of guarantee compromised their work in healthcare for patients (no. 138/253, 54.3%). Age correlated inversely with acknowledgment of defensive practices (r = -0.245, p < 0.001), with younger physicians more prone to defensive medicine (p = 0.013), particularly for patients at risk of suicide or violence. Psychiatrists in 'closed' settings (hospital wards, residential and rehabilitation centers, mental health service units in prison) reported more malpractice claims (p = 0.037) and complaints (p = 0.031), as well as a greater propensity to act defensively. In the treatment of patients with violent behavior, suicidal ideation, dual diagnoses, and criminal convictions, defensive practices were associated more with perceived legal risks (r = 0.306, p < 0.001) than actual legal involvement (p > 0.05). Anxiety, anger, and restlessness were common reactions to legal complaints, involving no. 50/254 (19.7%) respondents, with 40% reporting impaired functioning. Most psychiatrists (no. 175/253, 68.9%) were concerned about both civil and criminal laws regarding their professional responsibility, but many were not fully informed about recent legislative regulations and younger physicians resulted scarcely trained in risk management (p < 0.001). In conclusion, our findings suggest that defensive medicine is a common phenomenon among psychiatrists and their position of guarantee drives this attitude. Education on legal implications and risk management should be provided starting from the university and continuing over time, to improve the knowledge of young and senior doctors on professional liability and inform their decision-making processes. This would also reduce defensive practices and improve the quality of healthcare. Considering the concerns of younger physicians, as well as of professionals working in acute and high-intensity medical care facilities, there is also an urgent need for a revision of the medical liability to ensure the sustainability of the National Health Service.

Treatment of Femoral Shaft Pseudarthrosis, Case Series and Medico-Legal Implications.

Pseudarthrosis (PSA) is a possible complication of femoral shaft fracture treatment. It is often associated with reduced bone quality and can, therefore, adversely affect quality of life. Its treatment poses a major challenge for orthopaedic surgeons. Several authors have set forth different surgical approaches for the treatment of pseudarthrosis, such as internal fixation with plate and screws, replacement of an intramedullary nail or prosthetic replacement. In cases associated with bone loss, osteopenia, or comminution of fracture fragments, autologous or homologous bone grafts may also be used. The chronic outcomes of the surgical treatment of femoral shaft pseudarthrosis, even when consolidation is achieved, are linked to disabling sequelae of clinical-functional relevance, deserving an adequate medico-legal evaluation. The purpose of this retrospective study is to analyse a clinical case series of patients treated for atrophic femoral shaft pseudarthrosis at the IRCCS Orthopaedic Institute Galeazzi, Milan, Italy, from 2014 to 2020 and their orthopaedic-traumatological and medico-legal implications.