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Radiation litigation and the nuclear industry--the experience in the United Kingdom.

In the United Kingdom, the Nuclear Installations Act 1965 places a "strict" statutory duty on the operators of nuclear facilities to ensure that any exposure to radiation resulting from operations does not cause injury or damage. A claimant does not have to prove fault to receive compensation under the Act, only causation. The 1965 Act has been fundamental in shaping litigation involving the nuclear industry in the UK. Civil law cases brought under the Act will be heard before a single judge (with no jury or technical assessor) who must present his or her decision in a reasoned judgment. This process leads to a considerable volume of expert evidence being presented to the court and extensive cross-examination of witnesses. The expense and uncertain outcome of cases involving claims by nuclear workers that occupational exposure to radiation had caused the development of cancer has led to employers and trade unions setting up the voluntary Compensation Scheme for Radiation-linked Diseases as an alternative to litigation. This Scheme has worked well and is held up as a model of alternative dispute resolution. However, a few cases concerning personal injury or damage to property have come before the courts when the defendant nuclear operator considered that the claims were technically unjustified and where settlement was not a policy option. As anticipated, these cases were lengthy, complex, and expensive. The radiation doses assessed to have been received by the individuals who were the subject of claims, whether workers or members of the public, have been crucial to the outcome. The technical expertise of health physicists and allied specialists has been vital in establishing defensible estimates of dose, and this contribution can be expected to remain of high importance in radiation litigation in the UK.

History, 20th Century↗

Malpractice litigation against child and adolescent psychiatry residency programs, 1981-1991.

A national survey was conducted to investigate malpractice litigation at United States child and adolescent psychiatry residency programs between 1981 and 1991. Fourteen percent of the directors of child and adolescent psychiatry reported at least one malpractice claim during this period. The highest percentage of lawsuits reported was in the northeast. Suicide and sexual abuse of latency age patients by other patients accounted for the most litigation. The mean monetary award was $167,000, and the largest award was $500,000 for discharge of a patient who killed his mother. There has been an increase in malpractice litigation during the past 10 years. Risk management strategies should be implemented to address areas of liability in child and adolescent psychiatry training programs.

Adolescent↗

Physicians' psychologic reactions to malpractice litigation.

A questionnaire investigating the psychologic sequelae of malpractice litigation was administered to sued and nonsued physicians through a major malpractice insurer in a rural southern state. Factor analysis showed clusters of symptoms, including psychologic trauma, job strain, shame/doubt, and active coping. Psychologic stress decreased with time (but did not return to baseline after 2 years), with winning a case, and with increased age. Stress was increased among those with cases pending or multiple suits. Female physicians used more active coping strategies, and being in a high-risk specialty led to greater job strain and active coping, regardless of litigation experience. Malpractice litigation is a major life trauma that should be dealt with as any other trauma, including use of positive coping strategies such as knowledge of the psychologic sequelae, cognitive reframing, and collegial and personal support systems.

Adaptation, Psychological↗

Characteristics of physicians who frequently act as expert witnesses in neurologic birth injury litigation.

OBJECTIVE: Much debate surrounds physicians who testify in controversial types of medical malpractice litigation, but little is known about them. We sought to describe characteristics of physicians who frequently act as expert witnesses in neurologic birth injury litigation. METHODS: Using jury verdict reports, we identified 827 cases between 1990 and 2005 involving birth-related neurologic injury to a child. Frequent expert witnesses were defined as those associated with more than 10 cases. From the verdict reports and other public data sources, we compiled case descriptions (injury type and severity, legal outcomes) and characteristics of the frequent witnesses (age, gender, board certification, academic publication record). We analyzed these characteristics by comparing witnesses with each other (plaintiff compared with defendant) and with nationally representative data. RESULTS: Seventy-one frequent witnesses participated in 738 cases (89% of the sample), which paid 2.9 billion US dollars in compensation. Most (56 of 71) testified for one side in at least three fourths of cases, and 40% of cases were located outside the witnesses' home states. Frequent plaintiff witnesses had a higher median annual case rate than their defendant counterparts (2.9 compared with 1.9 cases, P=.002). They were also older (57.2 compared with 50.8 years, P=.007), less likely to have subspecialty board certification (38% compared with 95%, P<.001), and had fewer academic publications (5.0 compared with 53.5, P=.002). CONCLUSION: A small cadre of physicians testifies in most neurologic birth injury litigation, and witnesses tend to act consistently for one side. Plaintiff witnesses have fewer markers of expertise than defendant witnesses. These descriptive and analytical findings may reflect suboptimal expertise or bias in physician expert testimony.

Birth Injuries↗

An overview of medical malpractice litigation and the perceived crisis.

In this overview of medical malpractice litigation in the United States, practical and philosophic aspects of the so-called malpractice litigation crisis are addressed. After reviewing the historical, legal rationale for compensating victims of negligent conduct by others, attention is focused on the plight of physicians who are charged with medical negligence and the oppressive insurance premiums that impose a heavy burden on all health care providers, particularly those in the surgical fields. A variety of political solutions advanced to "correct" the problem is reviewed. A historical prospective of malpractice litigation in the United States is presented together with an analysis of various legislative proposals--many of which have already been enacted in various states that will ostensibly "cure" the problems that concern clinicians. Consideration of the various legislative proposals includes: arbitrary limits on pain and suffering awards (caps); elimination of joint and several liability; regulation of attorneys fees; elimination of the collateral source rule; abrogation of punitive damages; proposals for periodic payments; and statutes of repose. Various procedural changes in the processing of malpractice claims are reviewed and analyzed from the perspective of both fairness and efficacy.

Crisis Intervention↗

Economics on trial: the use and abuse of economic methods in third party tobacco litigation.

OBJECTIVE: To analyse how the tobacco industry responded to economic models and methods used in third party payer tobacco litigation that has occurred since 1994. METHODS: Identified 12 third party payer cases and reviewed the transcripts using WinMax qualitative software. Focused on defendant's opening and closing statements, followed by trial testimony, depositions, and plaintiff's transcripts. RESULTS: Tobacco industry defendants tried to create doubt and confusion about whether or not smoking caused disease and by extension led to health care costs; argued that the economic models used were not legitimate and were not appropriate for estimating the costs incurred by plaintiffs; and criticised the data sources used because they did not consist of the individuals whose health care costs were being sought. CONCLUSIONS: Faced with a new and unprecedented wave of anti-tobacco litigation from third party payers, the tobacco industry tried to adapt strategies that had been used successfully in the past-creation of unfounded doubt and confusion, and manipulation of the discovery process to force plaintiffs to withdraw or concede defeat. The strategies failed because credible economic models of the health care costs of smoking had been developed that were able to quantify the damages to a large group of health care recipients, because plaintiff's attorneys were able to commit significant resources and willing to undertake substantial financial risk to defend their new legal approaches, and because previous arguments related to individual responsibility were deemed irrelevant in third party litigation.

Cost of Illness↗

Tobacco industry litigation position on addiction: continued dependence on past views.

This paper reviews the tobacco industry's litigation strategy for addressing the addiction issue through trial testimony by its experts, and opening and closing statements by its lawyers. Despite the fact that several companies now claim to accept, in varying degrees, the conclusions of the Surgeon General concerning tobacco addiction, the tobacco industry litigation strategy pertaining to addiction is essentially unchanged since that of the early 1980s when the issue emerged as crucial. The industry uses its experts and the process of cross-examination of plaintiff's experts to imply that the addictiveness of tobacco and nicotine are more comparable to substances such as caffeine, chocolate, and even milk, than to heroin, cocaine and alcohol. Furthermore, the tobacco industry contends that the definition of addiction has now become so broadened as to include carrots and caffeine and hence that any concurrence that smoking is addictive, does not imply that cigarettes are addictive to the standards that drugs such as heroin and cocaine are addictive. Finally, the industry has continuously asserted that tobacco users assumed the risks of tobacco since they understood that quitting could be difficult when they began to use, and moreover, that the main barrier to cessation is lack of desire or motivation to quit and not physical addiction. These positions have been maintained through the 2004-2005 US Government litigation that was ongoing as the time of this writing.

Biomedical Research↗

Tobacco industry litigation strategies to oppose tobacco control media campaigns.

OBJECTIVE: To document the tobacco industry's litigation strategy to impede tobacco control media campaigns. METHODS: Data were collected from news and reports, tobacco industry documents, and interviews with health advocates and media campaign staff. RESULTS: RJ Reynolds and Lorillard attempted to halt California's Media Campaign alleging that the campaign polluted jury pools and violated First Amendment rights because they were compelled to pay for anti-industry ads. The American Legacy Foundation was accused of violating the Master Settlement Agreement's vilification clause because its ads attacked the tobacco industry. The tobacco companies lost these legal challenges. CONCLUSION: The tobacco industry has expanded its efforts to oppose tobacco control media campaigns through litigation strategies. While litigation is a part of tobacco industry business, it imposes a financial burden and impediment to media campaigns' productivity. Tobacco control professionals need to anticipate these challenges and be prepared to defend against them.

Adolescent↗

Obstetric litigation: effects on clinical practice.

Many claims concerning extent and consequences of litigation have been made, despite a lack of comprehensive and widely available data. It has been suggested that a rapidly increasing rate of litigation has caused problems in the recruitment and retention of obstetricians, and has also caused practitioners to practice 'defensively'. This article discusses meaning and significance of defensiveness within obstetrics and midwifery and quantifies the incidence of certain examples of defensive practice. Based on large-scale postal surveys of obstetricians and midwives in Scotland and England, as well as follow-up interviews, it clarifies the significance of what has become known as defensive medicine in maternity care, notably in relation to caesarean sections. It then examines the role of clinical risk management, and the growth of protocols and guidelines in particular, in trying to limit litigation.

Cesarean Section↗

Sued and nonsued physicians' self-reported reactions to malpractice litigation.

To assess the impact of malpractice litigation on physicians' personal and professional lives, the authors surveyed a random sample of the Chicago Medical Society membership. Although both sued and nonsued physicians reported changes in professional behavior and emotional reactions to both the threat and actuality of litigation, sued physicians reported significantly more symptoms than nonsued physicians. Significantly more of them reported that they were likely to stop seeing certain types of patients, think of retiring early, and discourage their children from entering medicine. Malpractice litigation may affect not only physicians' personal and professional lives but also the delivery of health care.

Attitude of Health Personnel↗

The use of experts in medical malpractice litigation in Japan.

In medical malpractice litigation, the cooperation of medical experts is important. However, the appointment of experts has become problematic in Japan, apparently because many medical experts refuse to act in this capacity. However, this supposition has not until now been supported by quantitative evidence, since the fact that so few judgments in Japan are published made it impossible to investigate the situation. Therefore, we aim to show the state of the use of experts in medical malpractice litigation using objective data. Over the last ten years, the rate of the use of experts has averaged only 22.5%, varying according to region. Experts were used in 24.5% of cases involving an attorney on the patient's side, and in only 3.4% of cases where no attorney was used. The success rate of patients was higher when experts were adopted (39.1%) than when they were not (29.9%). The length of litigation involving experts was 4.0 years, and 2.7 years when no expert was involved. This research suggested the necessity of establishing a formal cooperation system as soon as possible in Japan with no regional maldistribution.

Expert Testimony↗

Unfinished business: how litigation relates to health care regulation.

"Regulation by litigation" is a recently recognized trend in American legal governance that develops differently in each economic sector it affects. In health care, widespread litigation can be viewed as the product of three partial transformations: incomplete industrialization, incomplete consumerism, and incomplete social solidarity. One can argue that the public turns to the courts because other actors who might exercise judgment and authority to resolve problems appear unreliable. Because litigation has several features at odds with sound health policy--including its cost, its hindsight bias, and its adversarial character--it may be necessary to develop new discretionary institutions to address specific questions that regulators cannot or will not answer.

Consumer Advocacy↗

Medical malpractice litigation related to gastrointestinal endoscopy in Japan: a two-decade review of civil court cases.

AIM: To examine the allegations in malpractice litigations related to gastrointestinal endoscopy in Japan. METHODS: A retrospective review of cases tried in the civil court system during the 21-year period from 1985 to 2005, identified in a computerized legal database, was undertaken. RESULTS: Eighteen malpractice litigations and a total of 30 allegations were identified. Of the 18 (44%) malpractice litigations, 8 (44%) were related to esophagogastroduodenoscopy, 4 (22%) to colonoscopy, 4 (22%) to endoscopic sphincterotomy, and 2 (11%) to endoscopic retrograde cholangiopancreatography. Seventeen (94%) cases pertained to complications, and the remaining (6%) case pertained to misdiagnosis. In 10 cases, the patient died of the complications. Allegations were categorized as: (1) performance error during the endoscopic procedure (n = 12, 40%); (2) lack of informed consent (n = 9, 30%); (3) performance error during the treatment after the endoscopic procedure (n = 4, 13%); (4) premedication error (n = 3, 10%); (5) diagnostic error (n = 1, 3%); and (6) indication error for the endoscopic procedure (n = 1, 3%). CONCLUSION: These data may aid in the design of risk prevention strategies to be used by gastrointestinal endoscopists.

Endoscopy, Gastrointestinal↗

Adverse events: reducing the risk of litigation.

How a physician deals with an adverse event, regardless of whether negligence or error played a role, can significantly influence whether medical malpractice litigation results. Honest communication and respect for patient confidentiality are as important in avoiding litigation as the quality of care provided. Clear, careful orders, sound documentation, and greater vigilance at transition points such as hospital admission and discharge help guard against error and litigation if errors occur.

Drug-Related Side Effects and Adverse Reactions↗

Identification of adverse events occurring during hospitalization. A cross-sectional study of litigation, quality assurance, and medical records at two teaching hospitals.

STUDY OBJECTIVES: To estimate the efficacy of a medical record review for identifying adverse events and negligent case suffered by hospitalized patients. DESIGN: Cross-sectional study comparing an objective medical record review with information available from hospital quality assurance records as well as risk management and litigation records. SETTING: Two metropolitan teaching hospitals in the northeastern United States. MEASUREMENTS AND MAIN RESULTS: Using the litigation and risk management records as a criterion standard, we found that the medical record review had a sensitivity of 80% (93 of 116; 95% CI, 73% to 88%) for discovering adverse events and a sensitivity of 76% (51 of 67; 95% CI, 66% to 86%) for discovering negligent care. We estimated that record review of a random sample of hospitalizations across a geographic region would have even higher sensitivity (adverse-event sensitivity, 84%; negligence sensitivity, 80%). Moreover, we found that the adverse events we failed to discover led to less costly malpractice claims. A significant number of adverse events (20 of 172) among hospitalizations never gave rise to litigation or risk management investigation. Six of the twenty were due to negligent care. Quality assurance efforts at the level of the clinical departments in one hospital led to review of only 12 out of 82 risk management records. CONCLUSIONS: The overwhelming majority of adverse events and episodes of negligent care are discoverable with the methods we used to evaluate medical records. Quality assurance efforts using similar record review methods should be further evaluated.

Cross-Sectional Studies↗

Practice guidelines and malpractice litigation: a two-way street.

OBJECTIVE: To understand how practice guidelines are used in malpractice litigation. DESIGN: Review of the open and closed malpractice claims of two medical malpractice insurance companies, and a mailed survey of attorneys who litigate malpractice claims. SETTING: United States. PARTICIPANTS: Two insurance companies and 960 randomly selected malpractice attorneys. MEASUREMENTS: Frequency and nature of the use of practice guidelines in litigation; understanding and frequency of the use of practice guidelines by attorneys in malpractice cases. RESULTS: 259 claims opened in 1990-1992 at two insurance companies, including all obstetrics and anesthesia claims and a random sample of other claims, were reviewed. Seventeen of these claims involved practice guidelines, which were used as exculpatory evidence (exonerating the defendant physician) in 4 cases and as inculpatory evidence (implicating the defendant physician) in 12 cases. The only physician or patient factors associated with use of a guideline was a longer physician-patient relationship (P = 0.021). Nine hundred and sixty surveys were mailed and 578 were returned (response rate, 60.1%). Attorneys reported that once a suit is initiated, practice guidelines are likely to be used for inculpatory purposes (inculpatory in 54% of cases; exculpatory in 22.7% of cases). However, guidelines that seem to offer exculpatory value induce attorneys not to bring suits. The only attorney factor associated with increased use of guidelines was a practice in which more than 50% of business was in medical malpractice. CONCLUSIONS: Guidelines are used both by plaintiffs' and defendants' attorneys in malpractice cases. The emphasis in health reform proposals on guidelines as exculpatory evidence should be carefully considered.

Humans↗

Records review for (in case of) litigation.

This article examined the role of records review in litigation. Ways to benefit from records analysis both before and during litigation were stressed. Use your records to improve documentation and reduce litigation.

Documentation↗

The question of validity of neuropsychological test scores among head-injured litigants: development of a dissimulation index.

Two groups of 20 head-injured subjects were studied. One group was involved in litigation related to the head injury and the other group was not involved in litigation. Every subject had been tested twice, with the intertest mean interval for the two groups ranging from 12.00 to 14.45 months, a statistically insignificant difference. Two indexes of consistency of test-retest performance, which have been reported previously (Reitan Dissimulation Index. Comparison of the distributions for the two groups on the Dissimulation Index revealed no overlap; in fact, a gap of several points separated the groups. Every litigation subject performed with less consistency than any nonlitigation subject. Using an approach based on intra-individual test comparisons shows promise of alleviating the vexing problem of invalidity of neuropsychological test results.

Journal Article↗