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A multifacited approach to improve patient safety, prevent medical errors and resolve the professional liability crisis.

The current professional liability crisis is the third in the last 30 years. Similarities of the 3 crises are the rising cost of professional liability insurance and a diminishing number of sources available to purchase coverage. Proposed tort reform with caps on noneconomic damages and attorney contingency fees is a back end approach and will do little to solve this crisis or prevent future ones. The current situation can only be solved by placing an increased emphasis on improving patient safety and elimination of all preventable medical errors. A national electronic medical record must be developed and rapid response teams need to be available in most hospitals. The protective devices of privileged communication and peer review are counterproductive and must be eliminated. Full and prompt disclosure of any medical error or injury needs to be made. Physicians must be taught proper communication skills and the importance of teamwork. Providers with frequent patient, nursing or medical staff complaints must be critically reviewed. The present system of risk management needs to move from a reactive position to a role of being proactive for both patient and physician. Claims management should offer the patient early compensation when appropriate and pursue a vigorous defense when medical care is adequate. Experts should be identified who will render fair, unbiased reviews of medical care with all of their findings being disclosed. Similar experts need to devise clear, concise, evidenced based standards of care for common medical conditions.

Humans↗

The thoracic surgical industrial complex.

The thoracic surgical industrial complex is an industry worth $2 billion per year and is shaped by six dominant forces, three positive and three negative. The three positive forces are technological innovation, entrepreneurial activity, and the flow of capital and the three opposing forces, government regulation, cost-containment, and the excessive costs of product liability insurance. We are now at a critical time in the evolution of this industry, with growth being enhanced in areas of lesser risk, namely, nonimplantable devices, at the expense of high-risk implantable devices. The future of the artificial heart hinges on the balance between the six forces, and this analysis examines the possibilities for timely development of this ultimate implantable device.

Consumer Product Safety↗

Twenty-eight years of clinical experience with implantable neuroprostheses for various applications.

Since 1973, the author has been implanting neural stimulators and later drug pumps to restore or improve motor function and modulate pain, spasticity, and seizures in patients with spinal cord and brain injury, cerebral palsy, stroke, and multiple sclerosis. During these 28 years, many physicians, biomedical engineers, and manufactures have realized worthwhile successes. Many lessons have been learned to improve operative techniques to ensure safety, low infection, and improved results for implant patients. The relationships between manufacturers and physicians have varied. Problems arise with patents, royalties, confidentiality, publishing, and liability insurance. There has been a need to patent ideas and intellectual properties; however, some of the patented concepts have been published previously but missed by the patent author and patent office. This has led to vigorous legal battles, consuming money with time delays, or resulting in surrendering worthwhile projects. There is a need for a responsible, independent appeals board to review these disputed patent claims. Then their findings should be admissible at the Patent Office and if necessary in court.

Biomedical Engineering↗

[Occupational exposure and cancer of the oral cavity and pharynx].

BACKGROUND: Occupational risk factors for the development of laryngeal cancer are well accepted, whereas the etiologic relationship between occupational exposure to various noxious influences and the development of cancer of the oral cavity and pharynx remain a matter of debate. Based on published data, occupational risk factors for cancer of the oral cavity and pharynx should be evaluated. METHODS: Publications since 1990 listed in the National Library of Medicine, textbooks and data obtained from the German Employer's Liability Insurance Association were evaluated. RESULTS: In several tobacco- and alcohol-adjusted case-control and cohort studies, an association with occupation in construction and metalworking industries, as painters, carpenters and machine operators was consistently found. The relative risks or standardized mortality rates ranged between 1.5 and 3. Some recent investigations found an association for workers in the paper and rubber industry. The results in regard to the textile and woodworking industry were inconclusive. CONCLUSION: In cases with moderate isolated tobacco or moderate isolated alcohol consumption, the risk attributable to occupational factors and smoking or drinking are of similar magnitude. According to German jurisdiction, a partial compensation of the acquired disability is then justified. In pronounced combined tobacco and alcohol consumption, the non-occupational risk factors increase exponentially and occupational risks attain marginal weight.

Adolescent↗

[Legal assessment of traumatic cataract for insurance purposes].

The author reports on differential diagnostic problems in the assessment of traumatic lens alterations. The question of the probability or possibility of a connection with the accident is discussed. A traumatic cataract, for example, is assessed differently by different types of insurance companies, since legal regulations governing insurance business differ. The author illustrates this with the assessment of a traumatic cataract by a statutory accident insurance company, a private accident insurance company, liability insurance companies, the statutory health insurance organization, the state pension fund and on the basis of the social indemnity legislation. The author points out the need for a basic knowledge of social legislation when giving an opinion.

Accidents, Occupational↗

Medical malpractice.

Medical liability insurance is in a state of emergency brough on by escalating premiums or withdrawal of insurance companies from the market. Solutions, supported by legislation, must be sought for the sake of both patient and physician. As a temporary method of correction joint underwriting associations appear to be the most practical suggestion. Long-range changes should include the establishment of powerful malpractice arbitration boards whose conclusions and evidence would be submitted in case of further appeal, the delegation of more power to the medical profession to enforce standards, shortening of the period specified in the statutes of limitation, limitations on contingency fees, and elimination of the applicability of such legal doctrines as ad damnum clauses and res ipsa loquitur.

Economics, Medical↗

Anaesthesia and the law: the North American experience.

The professional liability climate in the United States can best be described as tempestuous in most areas of the U.S. The major strategy of organized anaesthesia and the professional liability insurance industry is to attempt to reduce patient injury. In the unlikely eventuality that human error and equipment failure in anaesthesia can be eradicated, some patient injury will inevitably still occur. For this reason tort reform is necessary, and alternatives to the tort system need to be developed to compensate injured parties adequately without bankrupting the medical system.

Anesthesiology↗

Role of monitoring devices in prevention of anesthetic mishaps: a closed claims analysis.

Anesthesiologist-reviewers examined 1,175 anesthetic-related closed malpractice claims from 17 professional liability insurance companies. The claims were filed between 1974 and 1988. The reviewers were asked to determine if the negative outcome was preventable by proper use of additional monitoring devices available at the time of the review even if not available at the time the incident occurred, and if so, which devices could have been preventative. In 1,097 cases sufficient information was available to make a judgment regarding preventability of the morbidity or mortality by application of additional monitoring devices. It was determined that 31.5% of the negative outcomes could have been prevented by application of additional monitors. Using the insurance industry's scale of 0 (no injury) to 9 (death), the median severity of injury for incidents deemed preventable was 9 compared with 5 for those deemed not preventable (P less than 0.01, scale detailed in text). The severity of injury scores were the same for preventable mishaps occurring during regional or general anesthesia, suggesting that additional monitoring devices may be equally efficacious in preventing serious negative outcomes during either regional or general anesthesia. The judgements or settlements of the incidents judged preventable by additional monitoring were 11 times more costly (P less than 0.01) than those mishaps not judged preventable. The monitors determined by the reviewers to be most useful in mishap prevention were pulse oximetry plus capnometry. Applied together, these two technologies were considered potentially preventative in 93% of the preventable mishaps.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia↗

Rebuilding a rural obstetrical program: a case study.

The rebuilding of an obstetrical department of a small rural hospital (40 beds) in rural Nevada is described. The number of births at the hospital increased from 20 in 1981 to more than 300 for the past four years. The market share of obstetrical patients in the county increased from less than 10 percent in 1981, to an average of 80 percent for the last five years. The five major steps contributing to the success of this rebuilding program are described. Obstetrical malpractice liability insurance and the shaky financial viability of rural hospitals are discussed as the two major threats to rebuilding a rural obstetrical program. The experience in this setting suggests that rural residents want and desire local obstetrical care and that a team approach can rebuild a rural obstetrical capacity in a relatively short time.

Consumer Behavior↗

Physicians who treat the elderly in rural Florida: trends indicating concerns regarding access to care.

CONTEXT: Rural elderly patients are faced with numerous challenges in accessing care. Additional strains to access may be occurring given recent market pressures, which would have significant impact on this vulnerable population. PURPOSE: This study focused on the practice patterns and future plans of rural Florida physicians who routinely see elderly patients. Additionally, we examine those who provide services to a high volume of Medicare (HVM) patients. METHODS: A self-administered mailed survey was sent to rural physicians who identified themselves as practicing family medicine, internal medicine, psychiatry, general surgery, a surgical specialty, or a medical specialty. Questions examined changes in services offered by all rural physicians and among them, the HVM physicians. Impact of the professional liability insurance situation, satisfaction with current practice, and future practice plans on changes in service availability was also examined. RESULTS: Overall, 539 physicians responded for a participation rate of 42.7%. Two hundred eighty eight (54.9%) of all physicians in the study indicated a decrease or elimination of patient services in the last year. HVM physicians, compared to low volume of Medicare providers, were significantly more likely to decrease or eliminate services overall (66% vs 45%, P =.001). Mental health services (47% vs 18%, P =.001), vaccine administration (39% vs 16%, P =.008), and Pap smears (41% vs 13%, P =.008) were more likely to be eliminated among the HVM physicians. HVM physicians were also significantly more likely to be somewhat or very dissatisfied (40% vs 23%, P =.012) with their practice. CONCLUSIONS: Physicians in rural Florida report dissatisfaction with their practice and are decreasing or eliminating services that are important to the elderly. Given the aging population and increasing need for health care services, these trends raise concern about the ability for these patients to receive necessary care.

Adult↗

Patient allegations of sexual abuse--surviving a lawsuit.

In this article, the author examines patient allegations of sexual abuse by physicians, focusing on the legal theories for such suits and possible defenses, together with the complications of professional liability insurance coverage. In addition, practical suggestions for physicians charged with sexual misconduct are offered.

Humans↗

Medicare program; additional supplier standards--HCFA. Final rule with comment.

This final rule with comment period conforms our regulations to changes made to section 1834 of the Social Security Act (the Act) by section 131 of the Social Security Act Amendments of 1994. Section 1834(j) of the Act requires that suppliers meet additional standards related to compliance with State and Federal licensure requirements, maintaining a physical facility on an appropriate site, and proof of appropriate liability insurance. This final rule retains existing regulatory standards and incorporates the three additional standards specifically cited from the statute.

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

Putting to rest unwarranted fears about trustee liability.

Common concerns about the legal liability of trustees include malpractice, contracts, medical staff discipline, and conflict of interest. Each of these topics is discussed here, as well as the use of directors and officers liability insurance to protect against anticipated risks.

Governing Board↗

The current litigation crisis and tort reform.

We live in a litigious society. The resultant liability insurance crisis has had a major impact on almost every area of our lives. This article explores issues concerned with the litigation crisis and suggested reforms to lessen the stress caused to society.

Documentation↗

Florida's new approach to the medical liability crisis.

A new Florida medical liability insurance act went into effect on February 8, 1988. It would allow for prompt resolution of claims with mandatory presuit investigation of all claims and defenses and voluntary arbitration. A cap of $250,000 is placed on noneconomic damages without punitive awards. Refusal to arbitrate leads to a loss on limit on damages awardable at trial. Special provisions are made for birth-related neurological injury compensation.

Florida↗

Is the medical malpractice outlook really improving?

After climbing significantly over the past decade, medical liability insurance rates appear to be moderating as a result of declining frequency and severity of claims from late 1986 through 1988. A "softer" insurance climate with greater underwriting capacity also aided this process. However, experts believe that the moderation of rate increases may be short-lived because of the cyclical nature of the insurance marketplace and the insurer's difficulty in estimating claims and losses.

Forecasting↗

Dr. Discontent.

Physicians are angry, that that's bad news for hospitals. Increasingly, doctors are unable to pay soaring liability insurance premiuyms, are refusing to accept new Medicaid and Medicare patients, and are balking at taking ED calls. What's more, many physicians are setting up niche facilities that compete directly with hospitals in the most lucrative service lines.

Attitude of Health Personnel↗