What can we learn from the last 20 years: A review of litigation trends in otolaryngology

IntroductionLitigation in healthcare is a large financial burden to the NHS and can be a cause of great stress to clinicians. The overall number of claims across specialities, from the years 1995–2017 have increased. Despite being one of the smaller surgical specialities, litigation costs are still significant within Otolaryngology. In this piece we sought to analyse the available data to identify trends within litigation and therefore which areas of practise could be improved.MethodsA freedom of information request was submitted to NHS Resolution for summarised data on claims coded under ‘Otolaryngology’ or ‘ENT’ between 1996 and 2017. Information was collected on the total number of claims, the number of successful claims and details on the reasons for making claims.ResultsThe total number of claims made against Otolaryngology departments from 1996/97 to 2016/17 was 1952. The overall number of claims have increased during this time period. The total amount of money paid out between 1996 and 2017 was £108, 240, 323. The top causes of claim by injury were unnecessary pain and unnecessary operations. The highest number of claims by cause were for failure or delay in diagnosis and intraoperative problems.ConclusionThese results highlight areas that local units can focus on to reduce their litigation burden. Targeted initiatives aimed at improving patient-clinician communication, the consent process and improving local organisational efficiency will address a significant proportion of claims. Re-examination of this data on a regular basis can serve as a useful adjunct in assessing the impact of quality improvement initiatives and implementation of best practiseswithin the speciality.     

Learning from lawsuits: Ten-years of NHS litigation authority claims against 11 surgical specialities in England

Introduction

Medico-legal claims are a drain on NHS resources and promote defencive practice. The litigious burden of surgery in England has not been previously described. This paper describes trends over ten years of claims made against the NHS across 11 surgical specialities.

Litigation related to anaesthesia: analysis of claims against the NHS in England 2008–2018 and comparison against previous claim patterns

We reviewed all 1230 claims against anaesthesia notified to NHS Resolution (formerly the NHS Litigation Authority, 1995–2017) in England between 2008 and 2018. Claims were categorised by incident type, severity (whether physical or psychological), and cost, and comparisons were made against a similar published analysis of data from 1995 to 2007. While the annual number of claims against anaesthesia increased by 62% from the earlier period, anaesthesia now accounts for smaller proportions of all claims submitted to NHS Resolution (1.5% vs. 2.5%) and of the total cost of all claims (0.7% vs. 2.4%). The absolute costs related to anaesthesia claims rose over 300%, totalling £145 million between 2008 and 2018, but the mean cost per closed claim (retail price index adjusted) fell by 6% to £74,883. The most common clinical categories were regional anaesthesia (24%), inadequate anaesthesia (20%) and drug administration (20%). Claims related to airway management, central venous catheterisation and cardiac arrest remained infrequent but severe and costly. The proportion of claims relating to regional anaesthesia and obstetric anaesthesia fell significantly, but claims relating to peripheral nerve blockade doubled. Our analysis includes categories relating to organisational and human factors which are present in a substantial proportion of claims; categories with the highest mean cost per claim included delayed care, planning, monitoring and consent. Overall, the specialty of anaesthesia is at low risk of litigation. Our analysis provides important insights into current and changing patterns in claim distributions that may help improve the quality of patient care and reduce future litigation. We recommend the establishment of a structure for national review and learning from all cases of litigation.     

Litigation following groin hernia repair in England

Purpose

Since 1995, litigation following surgical procedures has cost the National Health Service (NHS) over 1.3 billion GBP (Great British Pounds)/2.1 billion USD (United States Dollars)/1.4 billion Euros. Despite it being the most commonly undertaken general surgical operation, no study has examined clinical negligence claims in England following groin hernia repairs.

Methods

Data from the NHS Litigation Authority of all claims made from 1995 to 2009 was obtained and interrogated.

Results

In total, 398 claims were made. Of these, 209 cases had been settled, of which 144 (46.6%) were in favour of the claimant to a cost of 7.35 million GBP/12 million USD/7.93 million Euros. Testicular injury and chronic pain featured in 40% of all claims. Visceral injuries and injuries requiring corrective procedures were the only predictors of a successful claim (P = 0.015 and P = 0.002, respectively). Claims associated with visceral and vascular injuries were more likely to occur in laparoscopic than in open repairs. Sexual dysfunction and chronic pain resulted in the highest average payouts of 85,467 GBP/140,565 USD/92,177 Euros and 81,288 GBP/133,693 USD/87,674 Euros, respectively.

Conclusion

Patients should be fully informed of the incidence of testicular injury and chronic pain during the consent process. Approaches minimising visceral and vascular injury particularly in laparoscopic repair should be adopted to reduce litigation and improve patient care.     

Analysis of NHSLA claims in orthopedic surgery

National Health Service (NHS) statistics in the United Kingdom demonstrate an increase in clinical negligence claims over the past 30 years. Reasons for this include elements of a cultural shift in attitudes toward the medical profession and the growth of the legal services industry. This issue affects medical and surgical health providers worldwide.The authors analyzed 2117 NHS Litigation Authority (NHSLA) orthopedic surgery claims between 1995 and 2001 with respect to these clinical areas: emergency department, outpatient care, surgery (elective or trauma operations), and inpatient care. The authors focused on the costs of settling and defending claims, costs attributable to clinical areas, common causes of claims, and claims relating to elective or trauma surgery. Numbers of claims and legal costs increased most notably in surgery (elective and trauma) and in the emergency department. However, claims are being defended more robustly. The annual cost for a successful defense has remained relatively stable, showing a slight decline. The common causes of claims are postoperative complication; wrong, delayed, or failure of diagnosis; inadequate consent; and wrong-site surgery. Certain surgical specialties (eg, spine and lower-limb surgery) have the most claims made during elective surgery, whereas upper-limb surgery has the most claims made during trauma surgery.The authors recommend that individual trusts liaise with orthopedic surgeons to devise strategies to address areas highlighted in our study. Despite differences in health care systems worldwide, the underlying issues are common. With improved understanding, physicians can deliver the service they promise their patients.     

Litigation related to inadequate anaesthesia: an analysis of claims against the NHS in England 1995–2007

Inadequate anaesthesia may cause distress to the patient and lead to medical litigation. All claims made to the NHS Litigation Authority 1995–2007 were obtained and the data was examined independently by all authors and classified. In a dataset of 1067 claims there were 161 cases of inadequate anaesthesia and data were suitable for analysis in 159: intra-operative awareness (79), brief awake paralysis (20) and inadequate regional anaesthesia (60). The total cost of closed claims was £3.2m. Cost was incurred in 100% of claims of brief awake paralysis, 87% of claims of awareness and 80% of claims of inadequate regional blockade. Mean cost of closed claims was £32 680 for anaesthetic awareness, £29 345 for inadequate regional blockade and £24 364 for brief awake paralysis. Inadequate anaesthesia accounts for 19% of anaesthesia-related claims in the NHS in England. Strategies that reduce anaesthetic awareness, drug errors and inadequate regional blockade are known and their improved implementation is likely to reduce such claims.     

Can spinal surgery in England be saved from litigation: a review of 978 clinical negligence claims against the NHS

Purpose

The aim of this study is to evaluate the true incidence of all clinical negligence claims against spinal surgery performed by orthopaedic spinal surgeons and neurosurgeons in the National Health Service (NHS) in England, including both open and closed claims.

Methods

This study was a retrospective review of 978 clinical negligence claims held by NHS Resolution against spinal surgery cases identified from claims against ‘Neurosurgery’ and ‘Orthopaedic Surgery’. This category included all emergency, trauma and elective work and all open and closed cases without exclusion between April 2012 and April 2017.

Results

Clinical negligence claims in spinal surgery were estimated to cost £535.5 million over this five-year period. There is a trend of both increasing volume and estimated costs of claims. The most common causes for claims were ‘judgement/timing’ (512 claims, 52.35%), ‘interpretation of results/clinical picture’ (255 claims, 26.07%), ‘unsatisfactory outcome to surgery’ (192 claims, 19.63%), ‘fail to warn/informed consent’ (80 claims, 8.13%) and ‘never events’ including ‘wrong site surgery’ or ‘retained instrument post-operation’ (26 claims, 2.66%). A sub-analysis of 3 years including 574 claims revealed the most prevalent pathologies were iatrogenic nerve damage (132 claims, 23.00%), cauda equina syndrome (CES) (131 claims, 22.82%), inadequate decompression (91 claims, 15.85%), iatrogenic cord damage (72 claims, 12.54%), and infection (51 claims, 8.89%).

Conclusions

The volume and costs of clinical negligence claims is threatening the future of spinal surgery. If spinal surgery is to continue to serve the patients who need it, most thorough investigation, implementation and sharing of lessons learned from litigation claims must be systematically carried out.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.

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Litigation costs of wrong-site surgery and other non-technical errors in orthopaedic operating theatres

Introduction

This study reviews the litigation costs of avoidable errors in orthopaedic operating theatres (OOTs) in England and Wales from 1995 to 2010 using the National Health Service Litigation Authority Database.

Materials and methods

Litigation specifically against non-technical errors (NTEs) in OOTs and issues regarding obtaining adequate consent was identified and analysed for the year of incident, compensation fee, cost of legal defence, and likelihood of compensation.

Results

There were 550 claims relating to consent and NTEs in OOTs. Negligence was related to consent (n=126), wrong-site surgery (104), injuries in the OOT (54), foreign body left in situ (54), diathermy and skin-preparation burns (54), operator error (40), incorrect equipment (25), medication errors (15) and tourniquet injuries (10). Mean cost per claim was £40,322. Cumulative cost for all cases was £20 million. Wrong-site surgery was error that elicited the most successful litigation (89% of cases). Litigation relating to implantation of an incorrect prosthesis (eg right-sided prosthesis in a left knee) cost £2.9 million. Prevalence of litigation against NTEs has declined since 2007.

Conclusions

Improved patient-safety strategies such as the World Health Organization Surgical Checklist may be responsible for the recent reduction in prevalence of litigation for NTEs. However, addition of a specific feature in orthopaedic surgery, an ‘implant time-out’ could translate into a cost benefit for National Health Service hospital trusts and improve patient safety.     

NHSLA litigation in hip fractures: Lessons learnt from NHSLA data

Hip fractures are a major cause of trauma related death, usually occurring in vulnerable elderly patients. There are an estimated 70,000 hip fractures in the UK per year with numbers set to rise. The estimated annual cost to the healthcare economy is in the region of £2 billion. A 17-year review examining litigation related to hip fractures was undertaken.Under a freedom of information request, data was obtained relating to all orthopaedic claims made to the NHS Litigation Authority (NHSLA) between 1995 and 2012. Data was filtered to identify cases involving hip fractures examining litigation trends related to this specific area.10263 NHSLA orthopaedic cases were identified, of which 13.3% (n = 1364) cases related to the hip and femur. Hip fractures made up 16.7% (n = 229). The total cost of hip fracture litigation was over £7 million with an average cost per case of £32,700. The commonest reasons for litigation were diagnostic errors (30.6%), issues with care (24.9%) alleged incompetent surgery (15.7%) and development of pressure sores (5.7%).This study highlights the main causes of litigation in patients sustaining hip fractures, with diagnosis in the emergency department and ward presenting a significant problem. In addition, the data identifies a range of care related issues, as well as several surgical factors and highlights the importance of pressure area care. We discuss these and make suggestions on how to improve practice in this area with the aim of improving patient care and reducing litigation.     

Urological litigation in the UK National Health Service (NHS): an analysis of 14 years of successful claims

What’s known on the subject? and What does the study add? There are no previous studies for urology in the UK but several studies from physician insurance groups in North America. There is anecdotal evidence of common reasons for litigation, e.g. missed testicular torsion. This is the first analysis of the claims data compiled by the NHS litigation authority for the speciality of urology; it provides realistic insight into the areas and procedures of the speciality most commonly affected by litigation. The article identifies areas of high risk, both clinical and medico‐legal.

OBJECTIVES

? To present a summary of the collected data on urological litigation within the UK National Health Service (NHS). ? Knowledge of the main areas of litigation is essential for maintaining good clinical practice as well as risk management procedures in any specialty.

MATERIALS AND METHODS

? Details of all claims closed with indemnity payment pertaining to the specialty of urology as practiced by urologists, general surgeons and paediatric surgeons was obtained from the NHS Litigation Authority (NHSLA) for the years since its creation in 1995 to 2009. ? The data was then classified and analysed.

RESULTS

? In all, 493 cases were closed with indemnity payment with a total of £20 508 686.18 paid. The average payment per claim was £41 599.77. ? Most of the claims were related to non‐operative events (232), followed by postoperative events (168) and intraoperative events (92). ? The most common reason for non‐operative‐related claims was failure to diagnose/treat cancer (69), perforation/organ injury (38) was the highest intraoperative‐related claim and a forgotten ureteric stent (23) was the most frequent postoperative‐related claim. ? The five most commonly implicated procedures were ureteroscopy/ureteric stenting (45), transurethral resection of the prostate (30), nephrectomy (26), vasectomy (19) and urethral catheterisation (15).

CONCLUSIONS

? The present study once again emphasizes the importance of thorough clinical assessment, record keeping and follow‐up as well as informed consent and good communication with patients. ? Recognising the areas of highest risk and improving practice should limit future claims.     

A nine-year review of medicolegal claims in neurosurgery

Introduction

Neurosurgery remains among the highest malpractice risk specialties. This study aimed to identify areas in neurosurgery associated with litigation, attendant causes and costs.

Methods

Retrospective analysis was conducted of 42 closed litigation cases treated by neurosurgeons at one hospital between March 2004 and March 2013. Data included clinical event, timing and reason for claim, operative course and legal outcome.

Results

Twenty-nine claims were defended out of court and twelve were settled out of court. One case required court attendance and was defended. Of the 42 claims, 28, 13 and 1 related to spinal (0.3% of caseload), cranial (0.1% of caseload) and peripheral nerve (0.07% of caseload) surgery respectively. The most common causes of claims were faulty surgical technique (43%), delayed diagnosis/misdiagnosis (17%), lack of information (14%) and delayed treatment (12%), with a likelihood of success of 39%, 29%, 17% and 20% respectively. The highest median payouts were for claims against faulty surgical technique (£230,000) and delayed diagnosis/misdiagnosis (£212,650). The mean delay between clinical event and claim was 664 days.

Conclusions

Spinal surgery carries the highest litigation risk versus cranial and peripheral nerve surgery. Claims are most commonly against faulty surgical technique and delayed diagnosis/misdiagnosis, which have the highest success rates and payouts. In spinal surgery, the most common cause of claims is faulty surgical technique. In cranial surgery, the most common cause is lack of information. Claims may occur years after the clinical event, necessitating thorough contemporaneous documentation for adequate future defence. We emphasise thorough patient consultation and meticulous surgical technique to minimise litigation in neurosurgical practice.     

Malpractice litigation in elective lumbar spinal fusion: a comprehensive review of reported legal claims in the U.S. in the past 50 years

BACKGROUND CONTEXTIn the U.S., medical malpractice litigation is associated with significant financial costs and often leads to the practice of defensive medicine. Among medical subspecialities, spine surgery is disproportionately impacted by malpractice claims.PURPOSETo provide a comprehensive assessment of reported malpractice litigation claims involving elective lumbar spinal fusion (LSF) surgery during the modern era of spine surgery instrumentation in the U.S., to identify factors associated with verdict outcomes, and to compare malpractice claims characteristics between different approaches for LSF.STUDY DESIGN/SETTINGA retrospective review.PATIENT SAMPLEPatients undergoing elective lumbar spinal fusion surgery.OUTCOME MEASURESThe primary outcome measure was verdict outcome (defendant vs. plaintiff verdict). Secondary outcome measures included alleged malpractice, injury/damage claimed, and award payouts.METHODSThe Westlaw legal database (Thomson Reuters, New York, NY, USA) was queried for verdict and settlement reports pertaining to elective LSF cases from 1970 to 2021. Data were collected regarding patient demographics, surgeon specialty, fellowship training, state/region, procedure, institutional setting (academic vs. community hospital), alleged malpractice, injury sustained, case outcomes, and monetary award.RESULTSA total of 310 cases were identified, yielding 67% (n=181) defendant and 24% (n=65) plaintiff verdicts, with 9% (n=26) settlements. Neurosurgeons and orthopedic spine surgeons were equally named as the defendant (45% vs. 51% respectively, p=0.59). When adjusted for inflation, the median final award for plaintiff verdicts was $1,241,286 (95% CI: $884,850–$2,311,706) while the median settlement award was $925,000 (95% CI: $574,800–$1,787,130), with no stastistically significant differences between verdict and reported settlement payouts (p=0.49). The Northeast region displayed significantly higher award payouts compared to other U.S. regions (p=0.02). There were no associations in awards outcomes when comparing alleged malpractice, alleged injuries/damages, institutional setting, surgical procedures, and surgeon specialty or fellowship training. The most common claims were intraoperative error (28%, n=107) followed by failure to obtain informed consent (24%, n=94). In the analyzed cohort, the most common injuries leading to litigation were refractory pain and suffering (37%, n=149) followed by permanent neurological deficits (26%, n=106). There were no differences in alleged malpractice or injury sustained between cases in which the outcome was favorable to defendant versus plaintiff. Anterior lumbar interbody fusion (ALIF) cases were 2.75 times more likely to be cited for excessive or inappropriate surgery (OR: 2.75 [95% CI: 1.14, 6.86], p=0.02) when compared to posterior surgical approaches.CONCLUSIONThe results of our analysis of reported claims suggest that medical malpractice litigation involving elective LSF is associated with jury verdicts over $1 million per case, with the most common alleged malpractice being intraoperative error and failure to obtain informed consent. Surgeon specialty, fellowship training, procedure type, and institution type were not associated with greater litigation risks; however, ALIF surgery had a significantly higher risk of involving claims of excessive or inappropriate surgery compared to posterior approaches for lumbar fusion. In addition, claims were significantly higher in the Northeast compared to other U.S. regions. Efforts to improve patient education through shared-decision making and proactive strategies to avoid, detect, and mitigate intra-operative procedural errors may decrease the risk of litigation in elective LSF.     

Negligence claims following non-union and malunion of long bone fractures: An analysis of 15 years of data

IntroductionNon-unions and malunions are recognised to be complications of the treatment of long bone fractures. No previous work has looked at the implications of these complications from a medicolegal perspective.MethodsA complete database of litigation claims in Trauma and Orthopaedic Surgery was obtained from the NHS Litigation Authority. Two separate modalities of the treatment of long bone fractures were examined i) non-union and ii) acquired deformity. The type of complaint, whether defended or not, and costs were analysed.ResultsThere were claims of which 97 related to non-union and 32 related to postoperative limb deformity. The total cost was £8.2 million over a 15-year period in England and Wales. Femoral and tibial non-unions were more expensive particularly if they resulted in amputation. Rotational deformity cost nearly twice as much as angulation deformities.ConclusionsThe cosmetic appearances of rotational malalignment and amputation results in higher compensation; this reinforces an outward perception of outcome as being more important than harmful effects. Notwithstanding the limitations of this database, there are clinical lessons to be gained from these litigation claims.     

Causes and Costs of a Decade of Litigation Following Emergency Appendectomy in England

Background

There has been recent interest in the delayed and nonoperative management of appendicitis. The present study assessed the causes and costs of litigation against surgeons following emergency appendectomy, with an emphasis on claims relating to preoperative management.

Materials and methods

Data were obtained from the English NHS Litigation Authority for claims relevant to appendectomy between 2002 and 2011. Two authors independently extracted data and classified it against predetermined criteria.

Results

Successful litigation occurred in 66 % of closed cases (147/223) with a total payout of £8.1 million. There were 24 claims against organizational operating room delays (9 % of total) and 27 against delayed diagnosis (10 %), with respective success rates of 70 and 68 %. From 21 claims relating to damage to fertility, nine were due to either delayed diagnosis or organizational operating room delays. Misdiagnosis was the second most common cause for litigation (16 %), but it had the lowest likelihood of success (49 %). Faulty surgical technique was the most common reason for litigation (39 %), with a 70 % likelihood of success. Of eight claims related to fatality, one was due to unacceptable preoperative delay leading to preventable perforated appendicitis. The overall highest median payouts were for claims of damage to fertility (£52,384), operating list delays (£44,716), and delayed diagnosis (£42,292).

Conclusions

There were significant medicolegal risks surrounding delays related to access to operating lists and diagnosis. Whereas future evidence regarding the safety of delayed appendectomy may provide scientific defense against these claims, the present study provides evidence of the current medicolegal risk to surgeons following delayed treatment of appendicitis.     

Trends in malpractice litigation in relation to the delivery of breast care in the National Health Service

Malpractice litigation involving the delivery of breast care has been evaluated in the United States of America (USA) but is a relatively new area of study in the United Kingdom (UK). We sought to study and evaluate the emerging trends in litigation claims in relation to breast disease with the National Health Service Litigation Authority (NHSLA) over the last 15 years, up to December 2010.     

The impact of system and diagnostic errors for medical litigation outcomes in orthopedic surgery

BackgroundMedical litigation resulting from medical errors has a negative impact on health economics for both patients and medical practitioners. In medical litigation involving orthopedic surgeons, we aimed to identify factors contributing to plaintiff victory (orthopedic surgeon loss) through a comprehensive assessment.MethodsThis retrospective study included 166 litigation claims against orthopedic surgeons using a litigation database in Japan. We evaluated the sex and age of the patient (plaintiff), initial diagnosis, diagnostic error, system error, the time and place of each claim that led to malpractice litigation, the institution's size, and clinical outcomes. The main outcome was the litigation outcome (acceptance or rejection) in the final judgment. Acceptance meant that the orthopedic surgeon lost the malpractice lawsuit. We conducted multivariable logistic regression analyses to examine the association of factors with an accepted claim.ResultsThe median age of the patients was 42 years, and 65.7% were male. The litigation outcome of 85 (51.2%) claims was acceptance. The adjusted median indemnity paid was $151,818. The multivariable analysis showed that diagnostic error, system error, sequelae, inadequate medical procedure, and follow-up observation were significantly associated with the orthopedic surgeon losing the lawsuit. In particular, claims involving diagnostic errors were more likely to be acceptance claims, in which the orthopedic surgeon lost (adjusted odds ratio 16.7, 95% confidence intervals: 4.7 to 58.0, p < 0.001). All of the claims in which the orthopedic surgeon lost were associated with a diagnostic or system error, with the most common one being system error.ConclusionsSystem errors and diagnostic errors were significantly associated with acceptance claims (orthopedic surgeon losses). Since these are modifiable factors, it is necessary to take measures not only for individual physicians but also for the overall medical management system to enhance patient safety and reduce the litigation risk of orthopedic surgeons.     

Professional Liability in Orthopaedics and Traumatology in Italy

Background

Interest in medical errors has increased during the last few years owing to the number of medical malpractice claims. Reasons for the increasing number of claims may be related to patients’ higher expectations, iatrogenic injury, and the growth of the legal services industry. Claims analysis provides helpful information in specialties in which a higher number of errors occur, highlighting areas where orthopaedic care might be improved.

Questions/purposes

We determined: (1) the number of claims involving orthopaedics and traumatology in Rome; (2) the risk of litigation in elective and trauma surgery; (3) the most common surgical procedures involved in claims and indemnity payments; (4) the time between the adverse medical event and the judgment date; and (5) issues related to informed consent.

Methods

We analyzed 1925 malpractice judgments decided in the Civil Court of Rome between 2004 and 2010.

Results

In total, 243 orthopaedics claims were filed, and in 75% of these cases surgeons were found liable; 149 (61%) of these resulted from elective surgery. Surgical teams were sued in 30 claims and found liable in 22. The total indemnity payment ordered was more than €12,350,000 (USD 16,190,000). THA and spinal surgery were the most common surgical procedures involved. Inadequate informed consent was reported in 5.3% of cases.

Conclusions

Our study shows that careful medical examination, accurate documentation in medical records, and adequate informed consent might reduce the number of claims. We suggest monitoring of court judgments would be useful to develop prevention strategies to reduce claims.     

Complications and patient-injury after ankle fracture surgery. −A closed claim analysis with data from the Patient Compensation Association in Denmark

BackgroundThe Patient Compensation Association (PCA) receives claims for financial compensation from patients who believe they have sustained damage from their treatment in the Danish health care system. In this study, we have analysed closed claims in which patients suffered injuries due to the surgical treatment of their ankle fracture. We identified causalities contributing to these injuries and malpractices, as well as the economic consequences of these damages.MethodsFifty-one approved closed claims from the PCA database from the years 2004–2009 were analysed in a retrospective systematic review. All patients were adults with an iatrogenic injury, and received compensation. A root cause analysis was performed to identify whether the patient suffered the damage preoperatively, during surgery or postoperatively, and to determine the level of education of the injurious doctor. Economic compensation, co-morbidities and end-result complications were registered.ResultsIn 9 of the cases the injuries happened preoperatively, but the majority of the injuries, namely 34 occurred during surgery. In 21 of the cases the damage happened postoperatively. Thirty percentages of the patients were mistreated in more than one phase. Level of competence was medical specialists in 2/3 and junior doctors in 1/3 of the cases. In the preoperative phase both groups were equally responsible for the inflicted damage. In the perioperative- and postoperative group, medical specialists inflicted the majority of damages. General recommendations regarding ORIF were not followed in 21/49 of the perioperative damages. The pronation fracture was the most common. The patients received a total average compensation of 17.561 USD each.ConclusionManaging the complex ankle fracture, requires considerable experience. This study indicates that extra attention should be paid to the most technically demanding fractures as the pronation-external-rotation-, diabetic- and fragility fractures. Surgeons should follow the recommendations for ORIF. Emphasis should also focus on adequate postoperative plans. This study finds a high readmission-burden, re-operation rate and great expenses in form of compensation.     

The pharmaco-economics of peri-operative statin therapy

We analysed the pharmaco-economics of the prospective peri-operative studies of statin administration for major elective vascular surgery, using the NHS reference costs for 2004. This analysis suggests that peri-operative statin therapy for patients undergoing vascular surgery may present the most cost-effective use of statin therapy yet described, with a number-needed-to-treat of 15 and almost 60% of the total cost of atorvastatin therapy recovered through a reduction in peri-operative adverse events.     

Trends in joint arthroplasty litigation over five years: the British experience

INTRODUCTION

Increasing numbers of joint arthroplasty are performed in Britain. While associated complications are well documented, it is not known which of those initiate malpractice claims.

METHOD

A five-year period was assessed for trends to highlight areas for further improvement in patient information and surgical management.

RESULTS

The National Health Service paid out almost £14 million for 598 claims. Forty per cent of this was for legal costs. The number of claims increased over time while the rate of successful claims decreased.

CONCLUSIONS

A failure to consent adequately and to adhere to policies and standard practice can result in a successful malpractice claim. Protecting patients intrao-peratively and maintaining high technical expertise while implementing policies and obtaining informed consent decreases the litigation burden.