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PubMed1997

Malpractice in the lower Rio Grande Valley.

Data from the National Practitioner Data Bank were examined to assess malpractice payments in the Lower Rio Grande Valley in comparison with those for Texas and the United States as a whole. The Valley was found to have a high rate of malpractice payments when considered on a per physician basis and on a per unit of utilization basis, but an average rate when considered on a population basis. A number of possible explanations (such as the "bad apple" theory, the "settlement for convenience" theory, the case distribution theory, the physician qualifications theory, and the foreign medical graduate theory) were examined to explain the Valley's observed rate of malpractice payments per physician. No explanations are particularly satisfactory. More research is needed, but indications suggest that the observed rate may be driven more by the activities of some attorneys than by the actions of Valley physicians.

Delivery of Health Care↗
PubMed1997

Practice guidelines & medical malpractice litigation.

In 1973, the United States Congress enacted legislation requiring physicians to initiate Peer Review Organizations to monitor utilization and quality of hospital and physician services in the federally funded Medicare program. A hardly noticed provision of the statute intimated the desirability of formulating guidelines for medical treatment. What was originally intended to simplify and universalize general standards by which quality of care could be objectively measured has more recently escalated into formalized projects, subsidized by government, to create "practice parameters". The impetus to define clinical conditions and methods of treatment for specific medical conditions (practice parameters) and standards of practice to avoid or defend malpractice claims (risk management protocols) are part of the movement in the United States for tort reform. If the vague "reasonable man" standard of care in negligence law can be supplanted by a scientifically developed, particularized medical practice standard, it is anticipated that spurious claims and defensive medical practice will be discouraged, quality improved, iatrogenic injury and malpractice litigation diminished. Many U.S. states undertook tort reform in the last decade. A few have embarked on medical-legal reform. One state is conducting a five-year medical liability project that calls for the development of practice parameters and risk management protocols in four medical specialties. The parameters will have the effect of law and may be introduced as evidence in medical malpractice trials. How the parameters are established, their effect on the strategies of litigation, the resultant trial problems in the introduction of evidence and in the burden of proof and their potential for acceptance by a significant number of jurisdictions-are the issues to be explored in this paper.

Humans↗
PubMed1976

Study points to the potential of arbitrating malpractice claims.

The Southern California Arbitration Project has demonstrated that arbitration may be applied successfully within the hospital segment of the health care industry. Although results are inconclusive at this time, arbitration may be a feasible alternative to litigation in securing expeditious and inexpensive resolution of malpractice cases. Of course, arbitration, in and of itself, is no panacea for the critical malpractice problem currently experienced throughout the nation; however, its potential for substantive contribution toward the resolution of malpractice claims is worthy of extensive experimentation and evaluation.

California↗
PubMed1976

[Malpractice in psychotherapy].

Two cases of malpractice in psychotherapy are described. In one case there was a psychiatrist involved, in the other a non-medical psychotherapist. The legal aspects of malpractice in the view of Swiss legislation are shortly discussed. A legal liability for damages caused by the psychotherapist might arise if the following conditions are fulfilled: A deviance from the generally accepted standards of care in psychotherapy, a damage to the patient as a consequence of this deviance and a negligence on the part of the psychotherapist. Furthermore, there has to be an adequate causal nexus between malpractice and damage done to the patient. By some case reports the author tries to exemplify what can be understood by the term of generally accepted standards of care in psychotherapy.

Depression↗
PubMed2005

Defensive medicine among high-risk specialist physicians in a volatile malpractice environment.

CONTEXT: How often physicians alter their clinical behavior because of the threat of malpractice liability, termed defensive medicine, and the consequences of those changes, are central questions in the ongoing medical malpractice reform debate. OBJECTIVE: To study the prevalence and characteristics of defensive medicine among physicians practicing in high-liability specialties during a period of substantial instability in the malpractice environment. DESIGN, SETTING, AND PARTICIPANTS: Mail survey of physicians in 6 specialties at high risk of litigation (emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology) in Pennsylvania in May 2003. MAIN OUTCOME MEASURES: Number of physicians in each specialty reporting defensive medicine or changes in scope of practice and characteristics of defensive medicine (assurance and avoidance behavior). RESULTS: A total of 824 physicians (65%) completed the survey. Nearly all (93%) reported practicing defensive medicine. "Assurance behavior" such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%). Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents' lack of confidence in their liability insurance and perceived burden of insurance premiums. CONCLUSION: Defensive medicine is highly prevalent among physicians in Pennsylvania who pay the most for liability insurance, with potentially serious implications for cost, access, and both technical and interpersonal quality of care.

Defensive Medicine↗
PubMedDate not supplied

The effects of malpractice insurance on certified nurse-midwives. The case of rural Arizona.

This study of CNMs in rural Arizona indicated malpractice insurance has had a negative effect on the practice of nurse-midwifery. In 1987 a telephone survey was conducted to assess the effects on the practice patterns of Arizona's 21 rural CNMs, four of whom had had previous experience as licensed midwives. Results indicated 24% had been refused medical back-up by a physician. Although 10% were personally responsible for paying malpractice insurance premiums, they were not able to afford the cost and were going "bare." Nearly 30% had changed their employment status from private practitioner to salaried employee, suffering a decrease in professional autonomy, flexibility of hours, quality of lifestyle, benefits, and income. Unless there are changes that result in lower malpractice insurance premiums or greater compensation and benefits, there likely will be a diminishing number of entries into an increasingly stressed profession.

Arizona↗
PubMed1985

Guidelines for treatment of malpractice claims reduces diversity.

Various accounting practices are used for the treatment of medical malpractice claims, related malpractice insurance, and trust funds. To decrease the diversity of accounting practices in these areas and provide more specific guidance to healthcare providers, the AICPA has issued several proposed guidelines concerning accounting treatment of asserted and unasserted medical malpractice claims, providers' claims-made insurance policies, retrospectively rated insurance premiums, captive insurance companies, and trust funds.

Accounting↗
PubMed1987

Medicare and Medicaid programs; payment for the cost of malpractice insurance--HCFA. Confirmation of final rule.

In this document, we are addressing public comments received in response to the interim final rule on payment for the cost of malpractice insurance, insurance, published on April 1, 1986. (51 FR 11142.) In that interim final rule, we established a specific methodology for apportionment of hospital malpractice insurance cost (that is, the cost of premiums or self-insurance) under Medicare that relied on, in part, a "scaling factor formula." We also provided for apportionment of skilled nursing facility malpractice insurance cost on the basis of Medicare patient utilization. With respect to the Medicaid program and the Maternal and Child Health program, we deferred to the States instead of establishing payment methodologies for these programs. As a result of our consideration of timely comments on the interim final rule and reevaluation of appropriate data, we plan to specify the values of the factors used in the scaling factor formula for the hospital methodology separately for short-term acute care hospitals and other hospitals. Accordingly, we have recomputed the values of the factors in the formula and, in this document, we are establishing values for short-term acute care hospitals. The values are the same as those announced in the interim final rule for all hospitals. We will issue another Federal Register document as soon as possible in which, as noted above, we intend to establish the values to be used in applying the formula to other hospitals. In the interim, for these other hospitals, we will continue to use the same formula values that were established in the interim final rule. We are not changing any of the other policies established in the interim final rule.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1963

THE CALIFORNIA MEDICAL MALPRACTICE PICTURE.

The California physician's steadily increasing risk of legal liability poses a basic question: Will he ultimately wind up a guarantor of results, carrying a great burden of malpractice insurance in order to pay for every untoward result of medical treatment? This alarming prospect is the result of many years of judicial (and therefore lay) speculation on the legal significance of the injury which brings the patient into court. Does it look as though this injury probably is associated with medical negligence? If so, let the doctor explain. And the explanation must be very complete. The legal instrument which thus reverses the traditional requirements of proof, permitting the patient-plaintiff to remain silent while the doctor-defendant must exculpate himself, is an evidentiary doctrine called res ipsa loquitur-the thing speaks for itself. The application of the doctrine relieves the patient-plaintiff of the necessity of producing an expert witness to point the finger and say, "The medical conduct that produced this injury was sub-standard." The increased use of the doctrine reflects a judicial conviction that in many parts of California physicians refuse to testify for the patient-plaintiff regardless of the merit to his case.A recent California Supreme Court decision suggests that the Court is not unaware of the adverse social consequences implicit in the irrational expansion of the physician's risk of legal liability. But a reversal of this trend would seem to be contingent on positive conduct from the medical profession in California-conduct demonstrating that no meritorious patient-plaintiff will fail in his malpractice lawsuit for lack of an expert medical witness.

California↗
PubMed2005

Emerging credentialing practices, malpractice liability policies, and guidelines governing complementary and alternative medical practices and dietary supplement recommendations: a descriptive study of 19 integrative health care centers in the United States.

BACKGROUND: Little is known about policies governing the integration of complementary and alternative medical (CAM) therapies and providers. METHODS: To document emerging approaches in 19 US hospitals regarding credentialing, malpractice liability, and pharmacy policies governing integration of CAM therapies and providers into conventional medical settings, we surveyed 21 academic medical centers and 13 non-academically affiliated hospitals that are nationally visible and are integrating CAM therapies into conventional medical settings. Of the 19 respondents, 11 were tertiary care hospitals, 6 were community hospitals, 1 was a freestanding center associated with a community-based hospital, and 1 was a university-based rehabilitation hospital. RESULTS: Institutions had no consistent approach to provider mix and authority within the integrative care team, and minimum requirements for professional liability insurance, informed consent disclosure, and hiring status. Less than a third had a formal (stated) policy concerning dietary supplements; those selling supplements in their pharmacy lacked consistent, evidence-based rationales regarding which products and brands to include or exclude. Although many hospitals confiscated patient supplements on admission, institutions had inconsistent criteria regarding allowance of home supply. CONCLUSIONS: Hospitals are using heterogeneous approaches to address licensure, credentialing, scope of practice, malpractice liability, and dietary supplement use in developing models of integrative care. The environment creates significant impediments to the delivery of consistent clinical care and multisite evaluations of the safety, efficacy, and cost-effectiveness (or lack thereof) of CAM therapies (or integrative models) as applied to management of common medical conditions. Consensus policies need to be developed.

Complementary Therapies↗
PubMed1996

Ophthalmic malpractice lawsuits with large monetary awards.

Malpractice claims against ophthalmologists that were closed with patient indemnification of at least $250,000(18% of all eye claims closed with payments to patients) were analyzed for risk prevention. The incident of alleged malpractice occurred within 1 month of the initial physician-patient encounter in 43% of claims and on the initial encounter in 17%. Cataract was the most frequent problem for which these patients sought treatment. Eighty-four percent of these patients sustained injuries resulting in legal blindness or worse. The most frequent complication of treatment (25%) was failure or delay in diagnosis of detached retina, or negligent treatment resulting in a retinal detachment. The most frequent factors influencing the decision to seek a settlement included altered records, poor documentation, informed consent problems, failure to see the patient promptly, and failure to obtain or follow the advice of a consultant.

Adolescent↗
PubMed1975

Protection against malpractice litigation.

Malpractice insurance costs are based on loss experience and defenses of expenses. Physicians in the high-risk category are in that position because, as a group, they have a high frequency of claims, a high average cost, or both. True, "defensive medicine" is the best way to minimize the risks. This does not mean ordering unnecessary tests or refusal of essential treatment. Rather, it is the habit of exercising extra care and foresight to avoid medical hazards and to apply prompt remedial measures when they occur. It means being aware of the patient's personality and needs. It means taking time to talk to the patient about proposed procedures and their risks. This kind of "defensive medicine" offers the best hope for reducing the frequency and cost of claims that result in the present critical malpractice problems.

Communication↗
PubMed1991

Obstetrics and malpractice. Evidence on the performance of a selective no-fault system.

Most malpractice litigation in obstetrics could be replaced with an alternative insurance system based on "accelerated-compensation events," which are classes of medical injuries determined in advance by medical experts to be readily identifiable, normally preventable with good care, and nondistorting of medical decision making. This professionally derived system would help prevent injury and improve the resolution of injuries. Prior work on accelerated-compensation events was largely conceptual, so to study the likely effects of accelerated-compensation events, we applied the events to a large database of obstetrical malpractice claims. Results refute prior criticisms. Accelerated-compensation events (1) are definitely feasible to develop and apply, (2) would probably cover two thirds of currently paid claims and three quarters of indemnity dollars, (3) would likely involve substantial savings in time and expense per case, and (4) would probably not introduce an unmanageable number of large new claims.

Defensive Medicine↗
PubMed2002

Patient complaints and malpractice risk.

CONTEXT: A small number of physicians experience a disproportionate share of malpractice claims and expenses. If malpractice risk is related in large measure to factors such as patient dissatisfaction with interpersonal behaviors, care and treatment, and access, it might be possible to monitor physicians' risk of being sued. OBJECTIVE: To examine the association between physicians' patient complaint records and their risk management experiences. DESIGN, SETTING, AND PARTICIPANTS: Retrospective longitudinal cohort study of 645 general and specialist physicians in a large US medical group between January 1992 and March 1998, accounting for 2546 physician-years of care. MAIN OUTCOME MEASURES: Computerized records of all unsolicited patient complaints were recorded by the medical center's patient affairs office, coded to characterize the nature of the problem and alleged offender, and compared with each physician's risk management records for the same period. RESULTS: Both patient complaints and risk management events were higher for surgeons than nonsurgeons. Specifically, 137 (32%) of the 426 nonsurgeons had at least 1 risk management file compared with nearly two thirds (137 [63%] of 219) of all surgeons (chi2(1)= 54.7, P<.001). Both complaint and risk management data were positively correlated with physicians' volume of clinical activity. Logistic regression revealed that risk management file openings, file openings with expenditures, and lawsuits were significantly related to total numbers of patient complaints, even when data were adjusted for clinical activity. Predictive concordance of specialty group, complaint count, clinical activity, and sex for risk management file openings was 84%; file openings with expenditures, 83%; lawsuits, 81%; and multiple lawsuits, 87%. CONCLUSIONS: Unsolicited patient complaints captured and recorded by a medical group are positively associated with physicians' risk management experiences.

Humans↗
PubMed1993

Medical malpractice involving colon and rectal disease: a 20-year review of United States civil court litigation.

To determine objectively the causes of malpractice litigation involving colon and rectal disease, a retrospective review was undertaken of all cases tried in the U.S. federal and state civil court system over a 21-year period from 1971 through 1991. Ninety-eight malpractice cases were identified from a computerized legal data base, involving 103 allegations of negligence. Allegations fell into five major categories: 1) failure to timely diagnose disease, principally colorectal cancer and appendicitis (n = 44/103; 43 percent); 2) iatrogenic colon injury (n = 25/103; 24 percent); 3) iatrogenic medical complications during diagnosis or treatment (n = 16/103; 15 percent); 4) sphincter injury with fecal incontinence, resulting from anorectal surgery or midline episiotomy (n = 10/103; 10 percent); and 5) lack of informed consent, especially regarding extent of procedures or risk of endoscopy (n = 8/103; 8 percent). These data may aid in design of risk prevention strategies related to the diagnosis and treatment of colorectal disease.

Anal Canal↗
PubMedDate not supplied

Expert testimony based on decision analysis: a malpractice case report.

OBJECTIVE: Expert testimony in malpractice cases is often subjective and biased. Decision-analytic techniques might provide an objective basis for such testimony. DESIGN: Case report. This article reports the case of a patient with chest pain that resulted in a malpractice suit alleging a delay in diagnosis of coronary artery disease. SETTING: The case occurred in a private practice; the expert witnesses and the decision analysis originated from a university teaching hospital. METHODS: A decision tree and threshold analysis were used to define the thresholds of disease probability at which either testing or treatment should be implemented. The expert testimony of two witnesses that exercise stress testing was the standard of care was compared with the results of the decision analysis. MAIN RESULTS: Decision analysis supported the view that cardiac catheterization would have been the more appropriate test. CONCLUSIONS: Techniques of decision analysis provide a structured and quantitative basis for empirical judgment and may help to minimize current problems with expert testimony.

Chest Pain↗
PubMedDate not supplied

Malpractice: a case-control study of claimants.

Efforts by hospitals to minimize the frequency of malpractice claims require knowledge of which patients file claims and why. Utilizing a case-control method to investigate the characteristics of patients, of providers, and of the course of care at a university hospital, the authors found several factors to be associated with notification of an intent to file a claim. White collar workers, patients dissatisfied with their care, those who experienced more complications, and those admitted to a particular medical floor were more likely to make a claim. There was no significant association between notice of a claim and complexity of care as indicated by number of diagnoses, invasive procedures, blood tests, and x-rays. Furthermore, the number of different primary care physicians and different consultants did not influence the patient's decision to pursue legal action. Attention to these findings may help avert malpractice claims; however, further study with a larger sample is needed to validate these results.

Case-Control Studies↗
PubMed1998

[Reported malpractice after postoperative infection of the locomotor system. Analysis of 261 expert testimony evaluations].

Postoperative infection in the locomotor system may lead to malpractice suits. The aim of the study was to determine the success rate of these claims and the type of expert-confirmed medical negligence so that strategies for avoiding such negligence can be offered. A total of 261 degrees concerning suspected malpractice after postoperative infection in the locomotor system were retrospectively evaluated. Of these, 43.7% claims were successful. The most frequent type of negligence was late diagnosis (34.2%), followed by inconsistent treatment (27.2%) and insufficient surgical revision (5.3%). In 33.3%, combined types of negligence were found. Most frequently, negligence was suspected after infection following hand surgery and internal fixation of long bones. The highest success rate of claims was seen after puncture of joints (69.2%). Insufficient documentation was confirmed in 15.3%. The majority of negligence resulted from diagnostic and therapeutic doubts, which could be avoided, e.g., by a clear definition of infection, consultation of a second opinion, a 2nd-look operation, undelayed and radical surgical revision, painstaking follow-up and disciplined documentation.

Documentation↗