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The right of patients (parents) to know, in detail, the risks inherent in immunization procedures is an important issue. There is legal precedent for holding a physician or drug manufacturer liable for hazards inherent in immunizing materials even if no negligence is involved.
German employers' liability insurance associations or Berufsgenossenschaften (BGs)--institutions for statutory accident insurance--maintain a measurement system for hazardous substances, the so-called BGMG. The aim of the BGMG is to determine and document valid results of measurements of exposure primarily for prevention purposes. The data are collected systematically, in parallel to the sampling in a company. Parameters which are supposed to have a visible effect on exposure levels are documented. The MEGA database (documentation of measurement data relating to workplace exposure to hazardous substances) holds 1,629 million measurement values, which have been compiled in since 1972. The database offers a host of selection possibilities for assessments depending on the evaluation strategy.
The nursing home problem in Florida was characterized as a debate over quality of care and the rapid increase of lawsuits against nursing homes that led to a decline in the availability of affordable liability insurance. The staff for Florida's Task Force on Availability and Affordability of Long-Term Care analyzed lawsuit and quality-of-care data from one county in Florida and quality-of-care data statewide to understand the relationship between the two sides of the argument. Analyses showed support for both positions and a middle-ground policy position was achieved. The subsequent nursing home reform legislation and implications for the future of long-term care in Florida are discussed.
BACKGROUND: Nerve injury associated with anesthesia is a significant source of morbidity for patients and liability for anesthesiologists. To identify recurrent and emerging patterns of injury we analyzed the current American Society of Anesthesiologists (ASA) Closed Claims Project Database and performed an in-depth analysis of claims for nerve injury that were entered into the database since the authors' initial report of the subject. METHODS: The ASA Closed Claims Database is a standardized collection of case summaries derived from the closed claims files of professional liability insurance companies. Claims for nerve injury that were not included in the authors' 1990 report were reviewed in-depth. RESULTS: Six hundred seventy (16% of 4,183) claims were for anesthesia-related nerve injury. The most frequent sites of injury were the ulnar nerve (28%), brachial plexus (20%), lumbosacral nerve root (16%), and spinal cord (13%). Ulnar nerve (85%) injuries were more likely to have occurred in association with general anesthesia, whereas spinal cord (58%) and lumbosacral nerve root (92%) injuries were more likely to occur with regional techniques. Ulnar nerve injury occurred predominately in men (75%) and was also more apt to have a delayed onset of symptoms (62%) than other nerve injuries. Spinal cord injuries were the leading cause of claims for nerve injury that occurred in the 1990s. CONCLUSION: New strategies for prevention of nerve damage cannot be recommended at this time because the mechanism for most injuries, particularly those of the ulnar nerve, is not apparent.
Practice costs (not including liability insurance costs) account for approximately 41% of the payment for medical and surgical services in the Medicare Fee Schedule. Unlike the portion of the fee schedule that compensates physicians for their work, the practice cost portion of the Medicare Fee Schedule is not resource-based; it is based instead on historical charges. As a result, physicians can recover their practice costs in less time and with less effort (measured in work relative value units) by performing invasive procedures and tests than by providing evaluation and management services. The Physician Payment Review Commission has proposed, in some detail, a method for incorporating practice costs into the Medicare Fee Schedule. The method involves allocating indirect costs on the basis of physician work plus direct costs. We find, using their own analytical framework, that indirect costs should rather be allocated on the basis of time. But to better serve the goal of incentive neutrality, and to make practice cost payments more equitable, the payment a physician receives for practice costs should be based not on service mix and volume, but on characteristics of the physician's practice more closely related to practice costs: for example, whether the physician has an office, or whether the physician practices alone or in a group.
Historically, a newly graduated plastic surgeon in the United States could build a practice from his or her emergency room coverage. The historical cliche was for the surgeon to be affable, able, and available, and from that basis one's practice would grow. Emergency room exposure was an avenue for starting a practice, developing recognition, and, after that, building a referral pattern. Recently, the cross-shifting influence of management care, rising malpractice insurance costs, and risk ratio are changing this cliche to a crisis. An evaluation of a 2 1/2-year exposure to emergency room coverage has revealed a completely different profile. A total of 300 patient visits resulting in 69 surgical operations were evaluated for insurance and remuneration history. The findings indicated a significant remuneration dilemma for emergency room coverage. Interestingly, a remuneration problem exists in a market different from what one would expect. In this study, a sample from a suburban hospital, rather than an inner-city university hospital, is the greater problem.
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Simulation is a technique-not a technology-to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner. The diverse applications of simulation in health care can be categorised by 11 dimensions: aims and purposes of the simulation activity; unit of participation; experience level of participants; health care domain; professional discipline of participants; type of knowledge, skill, attitudes, or behaviours addressed; the simulated patient's age; technology applicable or required; site of simulation; extent of direct participation; and method of feedback used. Using simulation to improve safety will require full integration of its applications into the routine structures and practices of health care. The costs and benefits of simulation are difficult to determine, especially for the most challenging applications, where long term use may be required. Various driving forces and implementation mechanisms can be expected to propel simulation forward, including professional societies, liability insurers, health care payers, and ultimately the public. The future of simulation in health care depends on the commitment and ingenuity of the health care simulation community to see that improved patient safety using this tool becomes a reality.
Medically impairing injuries among medical personnel (n = 209) were analyzed based on data obtained from the Work-Related No-Fault Liability Insurance's (TFA) injury registration system. Almost half (98; 47%) were injured during patient care, of which 29 were injured as a result of physical trauma inflicted by the patient. When moving themselves between the homes of the patients and between different wards, 94 (45%) were injured (18 in vehicle crashes). The injuries most often resulting in medical impairment were sprains and/or strains (101; 48%) and fractures (67; 32%). The injuries primarily affected the upper extremities (48%). Fifteen percent had a medical impairment of 10% or more, and in about half of the cases, the impairment was 1% to 4%. Every injured person was on sick leave for 7 months, on average, during the 2-year follow-up period. In 12% of the cases, the injury led to a disability pension.
The objective of this study was to investigate a broad range of adverse health outcomes and their potential association to wood preservative used in daycare centers. This article focuses on reproductive effects. A sample of 221 exposed teachers was provided by the employer's liability insurers. A comparison group (n = 189) insured by the same two organizations was recruited from nonexposed daycare centers. In a face-to-face interview, job history and reproductive history of 398 female teachers were ascertained. Data on exposure were provided, including measurements on concentration of pentachlorophenol (PCP) and lindane in wood panels, and of PCP, lindane, polychlorinated dibenzo-p-dioxins and dibenzofurans in indoor air. An exposure matrix based on individual job history, independent exposure information from each center, and reproductive history was set up with regard to the vulnerable time windows for each pregnancy. Using this approach, 49 exposed and 507 nonexposed pregnancies were identified, including 32 exposed and 386 nonexposed live births. For subgroup analyses the observations were restricted to independent pregnancies, excluding multiple and consecutive births. The data were analyzed with linear regression techniques, taking confounders into account. The crude median difference between exposed and nonexposed was 175 g in birthweight and 2 cm in length. Controlling for confounders, the results show a significantly reduced but weight (p = 0.04) and length (p = 0.02) in exposed pregnancies, even after restricting the data to independent pregnancies and pregnancies for which data could be validated from the mother's health cards. These differences were not explained by differences in gestational age indicating that a toxic effect, which could cause small-for date newborns, might have affected the fetus.
Bariatric surgery is currently a rapidly growing subsection of general surgery, with exponential expansion over the past decade. Many residency programs lacked sufficient experience in bariatrics, necessitating established surgeons to consider re-training and re-vamping of their practice to enter the field. The addition of bariatric surgery to a general surgery practice can present economic consequences, which are both positive and negative. Positive consequences include a potential new revenue source with a large population base. Negative consequences include increased employees, required paper-work and office resources, increased malpractice premiums, difficulties with appropriate reimbursement, and limitations on access to appointment time for non-bariatric cases. This paper reviews the potential economic impact of bariatric surgery on a general surgery practice and possible alternatives to manage these efficiently.
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AIM: To clarify the prevalence of defensive medicine and the specific defensive medicine practices among gastroenterologists in Japan. METHODS: A survey of gastroenterologists in Hiroshima, Japan, was conducted by mail in March 2006. The number of gastroenterologists reporting defensive medicine behaviors or changes in their scope of practice and the reported defensive medicine practices, i.e., assurance and avoidance behaviors, were examined. RESULTS: A total of 131 (77%) out of 171 gastroenterologists completed the survey. Three (2%) respondents were sued, and most respondents (96%) had liability insurance. Nearly all respondents (98%) reported practicing defensive medicine. Avoidance behaviors, such as avoiding certain procedures or interventions and avoiding caring for high-risk patients, were very common (96%). Seventy-five percent of respondents reported often avoiding certain procedures or interventions. However, seasoned gastroenterologists (those in practice for more than 20 years) adopted avoidance behaviors significantly less often than those in practice for less than 10 years. Assurance behaviors, i.e., supplying additional services of marginal or no medical value, were also widespread (91%). Sixty-eight percent of respondents reported that they sometimes or often referred patients to other specialists unnecessarily. CONCLUSION: Defensive medicine may be highly prevalent among gastroenterologists throughout Japan, with potentially serious implications regarding costs, access, and both technical and interpersonal quality of care.
OBJECTIVE: To examine the impact of dog attacks by determining the incidence and risk factors for dog attacks. DESIGN: Injury surveillance data on dog attacks for a major metropolitan hospital were converted to incidence rates using 1991 census figures for the hospital catchment area and combined with data on community attitudes and experiences derived from a large community survey. SETTING: Queen Elizabeth Hospital (tertiary referral hospital), Adelaide, South Australia, January 1990 to July 1993. PARTICIPANTS: 356 victims of dog attacks who presented to the emergency department and 3093 respondents to the 1992 South Australian Health Omnibus Survey. MAIN OUTCOME MEASURES: Rates of dog attack by age and sex of the victim, hospital presentation and admission; differences in the representation of various dog breeds in attacks. RESULTS: About 6500 people are injured in Adelaide each year as a result of dog attacks and about 810 seek hospital treatment (7.3 per 10,000 people per year). Children aged 0-4 years were attacked and required hospital treatment twice as often as adults aged 21-59 years, and men aged over 76 years twice as often as men aged 36-75 years. Males were more at risk of attack than females for all age groups. Hospital admission rates were five times higher for the elderly (95% confidence interval [CI], 2.3%-10.2%) and seven times higher for children 12 years and under (95% CI, 3.4%-15.1%) compared with people aged 13-59 years; 90% of children were admitted because of head and facial bites. The risk of attack from german shepherds, bull terriers, blue/red heelers, dobermans and rottwellers was four to five times higher than for other common breeds. CONCLUSIONS: The public health implications of dog attacks are significant and there needs to be increased awareness of the risks to young children. Potential interventions to reduce the incidence of dog attacks vary from strict controls on high-risk breeds to mandatory leashing to a "user pays" liability insurance proposal.
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Healthcare institutions' growing diversity of business activities increasingly exposes them to antitrust liability. Greater exposure threatens assets not only of institutions, but of their officers and directors as well. Chief financial officers should be aware of emerging exposures and consider transferring risks through the use of directors' and officers' and entity liability insurance.
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