An analysis of causative factors in closed criminal medical malpractice cases of the Taiwan Supreme Court: 2000–2014

Most medical malpractice in Taiwan leads to criminal prosecution. This study examined the epidemiologic factors and clinical errors that led to medical malpractice convictions in Taiwanese criminal prosecutions. A retrospective, 15-year population-based review of criminal Supreme Court judgments pertaining to medical malpractice against physicians and nurses was conducted. Eighty-four cases were reviewed, yielding data that included the number and specialty involved, accused hospitals, the diagnosis, the time interval between incidents to closure, result of adjudication, the origin of cases (private vs. public prosecution), the result of medical appraisal, and the primary error. Overall, the cases averaged 7.6 years to achieve final adjudication. Seventy-five percent were settled in favor of the clinician; twenty-three physicians and three nurses were found guilty, but all of these avoided imprisonment via probation or replacement with forfeit. The single most risky specialty was emergency medicine (22.6% of the cases), with 36.8% of those resulting in guilty verdicts. The most common diagnosis groups were infectious diseases (23.8%), intracranial hemorrhages (10.7%), and acute coronary syndrome (9.5%). Public prosecutions had a 41.2% conviction rate; no guilty verdicts resulted from private prosecution. Nineteen (22.6%) cases were commuted, and 73.7% of those had a controversial appraisal result. The characteristics of criminal malpractice prosecution in Taiwan that could be improved to relieve the stress of frivolous lawsuits on the judicial process include lengthy jurisdiction process; low public-prosecution conviction rate; frequent commuted jurisdiction related to a controversial appraisal; and zero imprisonment rate for clinicians.     

Obstetric and gynecologic malpractice claims in Saudi Arabia: Incidence and cause

IntroductionThe occurrence of a bad outcome, injury or death of a patient during treatment increases the chance of malpractice litigation, increases legal responsibility and leads to increased fees for malpractice insurance. Physicians practicing obstetrics and gynecology face among the highest risks of malpractice litigation, and such litigation has led to an increase in the practice of defensive medicine and has made this specialty less appealing. Previous clinical data from Saudi Arabia have shown that more malpractice litigation concerns claims in obstetrics and gynecology than claims in any other field of medicine.ObjectiveTo identify the main causes of obstetrics and gynecology (OBGYN) professional liability claims in Saudi Arabia to have a better understanding and management of risks.MethodsAll OBGYN claims opened in Saudi Arabia between 2008 and 2013 were analyzed to identify the most common causes of claims. The results of these claims and the times until a final judgment made were also analyzed.ResultsOut of a total of 463 malpractice claims that were closed during the study period, 114 (24.6%) claims were in obstetrics and gynecology, and 92 (80.7%) of these claims concerned complications related to delivery room events. The most common causes of obstetric malpractice litigation were shoulder dystocia (brachial plexus injury) and fetal distress (hypoxic ischemic encephalopathy). Urinary system injury was the most common cause of gynecology cases. Most cases were decided in favor of the defendants with the exception of cases for which maternal and/or fetal death was the cause of litigation; nearly all of those cases were decided against the defendants.ConclusionObstetricians face a high risk of malpractice claims in Saudi Arabia, although most claims do not end in payments to plaintiffs. However, the effects of such claims on obstetric care should not be underestimated. Adherence to standards of care and careful documentation may decrease litigation and the number of indefensible malpractice claims.     

Factors affecting reporting of suspected child maltreatment in Saudi Arabia

Child maltreatment is a global issue. Child maltreatment can take many forms including neglect, physical abuse, emotional abuse, and sexual abuse. The aim of this review is to determine different factors that influence the lack of reporting of child maltreatment in Saudi Arabia. This paper classified these factors into barriers related to the cultural impact, healthcare practitioners, the abused children, and policy making. The cultural influence was manifested in the stigma around reporting due to lack of understanding of what child abuse is, perceiving it as a parental right to discipline a child, misunderstanding the Islamic laws, and diminished understanding of the long- and short-term consequences of child abuse. Healthcare professionals and students of healthcare specialties revealed not reporting suspected child maltreatment due to uncertainty of the occurrence of abuse, lack of knowledge on the matter, considering injuries to be unworthy of reporting, unawareness of protocols, prior negative experience after reporting, and the absence of strict legal consequences of not reporting. Abused children were found to rarely report maltreatment to authorities due to a variety of reasons such as lack of confidence, fear of breaking up their family, or being unaware of the occurrence of maltreatment in the first place. Saudi Arabia's public regulations do not specify when a physician should be concerned about improper conduct regarding child maltreatment. It is recommended that Saudi Arabia organizes child maltreatment awareness campaigns, intensifies the training of healthcare professionals, and sets precise mandatory reporting legislations. Child maltreatment is a problem that affects the society as a unit. Therefore, it mandates the collaboration of the whole community to eliminate this medico-social issue.     

Under-reporting of suicide in South Yorkshire (West): a retrospective study of suicide and open verdicts returned by HM Coroner, 1992-1997

A retrospective study was performed using information obtained from HM Coroner for South Yorkshire (West) over the period 1992-1997. All inquests which received a suicide or open verdict were reviewed to investigate the regional suicide statistics and the actual number of cases. Particular attention was paid to the age, sex, mental health and mode of death. There were 295 deaths believed to be suicidal in nature. Of these only 79% had suicide verdicts given and these comprise the official statistics. Of the open verdicts, many were suggestive of suicide but the circumstances were insufficient for the Coroner to be satisfied beyond reasonable doubt of the victims intention to kill themselves. Males and females had the same proportion of verdicts (80 and 76% respectively). Hanging was the commonest mode of suicide, (sex ratio 4.06 male: 1 female) and received a high percentage of suicide verdicts (81.5%). Self-poisoning was second but received suicide verdicts in only 66.3% of cases, whilst carbon-monoxide poisoning had a 98.1% rate of suicide verdict. Of the 295 cases, 202 decedents (88.5%) had a history of mental illness. Depression accounted for 153 cases (75.7%). Twelve decedents had psychotic illness (4%), one-half dying by jumping from a height. Official national data may under-report the annual suicide rate by over 20%. Deaths from poisoning by solid or liquid and jumping from a height appear particularly difficult to establish as suicide in coronial practice, with one-third of cases declared an open verdict.     

Investigating Errors in Medical Imaging: Lessons for Practice From Medicolegal Closed Claims

PurposeRadiology has lagged behind other disciplines in using medicolegal data to improve patient safety. The aim of this study was to characterize a sample of closed claims files to inform radiology practice and identify opportunities for system change.MethodsA retrospective analysis of 443 medicolegal closed claims provided to the Radiology Events Register. Data were provided by 2 medical defense organizations that provide medical indemnity insurance to Australian private practitioners. We calculated a procedural risk ratio (prevalence in the closed claims dataset divided by prevalence among all diagnostic imaging procedures reimbursed by the Australian Government over the corresponding timeframe) for each modality (CT, ultrasound, radiography, MRI, nuclear medicine) and some procedures. For each closed claim, the incident type was determined, and a classification of 12 patient safety fields was conducted.ResultsMisdiagnosis (delay or failure to correctly read imaging) accounted for 62% of error types. Modalities and procedures at higher risk of leading to a claim were: mammography (risk ratio [RR] = 4.0, 95% CI 2.9-5.5); breast ultrasound (RR = 2.8, 95% CI 1.7-4.7); total MRI (RR = 3.4, 95% CI 2.0-5.6); total CT (RR = 1.9, 95% CI 1.5-2.5), and obstetrics and gynecology ultrasound (RR = 1.9, 95% CI 1.4-2.4). Lower-risk modalities and procedures were: cardiac ultrasound (RR = 0.1, 95% CI 0.0-0.8); radiography extremities (RR = 0.7, 95% CI 0.5-0.9); and total radiography (RR = 0.8, 95% CI 0.7-0.9). Information to inform patient safety classification was limited, with a mean of 5.8 ± 1.8 (SD) fields available.ConclusionsDespite its limitations, medicolegal data deserve further attention from patient safety analysts.     

Rapid host nation medical deployment.

Rapid development of land-based units in Operation Desert Shield/Storm presented critical needs for medical support. Integration of small Navy mobile medical teams in Bahrain and a larger United States Army Hospital unit in Riyadh, Saudi Arabia, at host nation hospitals presented an innovative method of providing this support. The success of these ventures in convenience and quality of care establishes the host nation interaction with military medical professionals as a workable, satisfying, and important adjunct to standard military medical care.     

Medical malpractice: managing the risk

STUDY OBJECTIVE: This is an attempt to present an analysis of the literature examining objective information concerning the likelihood of medicolegal errors as it applies to current medical practice. Hopefully this information will be synthesized to generate a cogent approach to manage risk in emergency medicine. METHODS: Articles were obtained by an English language search of MEDLINE from January 1976 to July 2003. This computerized search was supplemented with literature from the author's personal medicolegal collection of peer review articles. This information was presented in a qualitative fashion. RESULTS: There was a steady increase in both the incidence and the recovery amount of verdicts involving general malpractice litigation. There are clearly high-risk emergency medicine categories responsible for most malpractice events, involving such commonly encountered conditions such as chest pain, abdominal pain, pediatric fever, central nervous system (CNS) bleeding, and abdominal aortic aneurysm (AAA). Interestingly, there is a second peak of more minor emergencies, specifically wounds with neglected foreign bodies and missed fractures. Clearly, the largest dollar amount recovery still involves chest pain with subsequent missed transmural myocardial infarction (MI). Interestingly, there does not appear to be a strong correlation between adverse events, outcome and medicolegal risk. Likewise, there does not appear to be a strong correlation between socioeconomic status and a propensity to sue, but there were some defined links with physician profiles involving past malpractice history, as well as prior adverse relationships or communication skills to subsequent claims. Interestingly, a significant association appears to be advertising placed by local law offices seeking to provide services. Lastly in the emergency medical services (EMS) realm, the single strongest correlate to malpractice was the likelihood of an ambulance accident and not related to care delivered itself. CONCLUSION: The current emergency medicine medicolegal dilemmas are a complex interaction of both patient and physician factors specifically targeting several disease categories and damage claims. Awareness of these issues can help to minimize subsequent medicolegal risk and improve patient care.     

A study to explore opinions and attitudes of Saudi Arabian MR professionals on the current status of routine MR scanner quality assurance testing in the Kingdom of Saudi Arabia

IntroductionInternationally it is recommended that quality assurance (QA) testing of MR systems is the responsibility of MR professionals to ensure efficient scanner performance. This study aims to explore the opinions and attitudes of MR professionals in the Kingdom of Saudi Arabia (KSA) regarding the current status of routine QA testing within MRI departments.MethodsA qualitative approach was adopted, with MR professionals working in public, semi-public and private hospitals in the KSA invited to participate in this interview-based study. A total of 52 individual semi-structured interviews were conducted with purposive sampling of MR radiographers and medical physicists based at 19 major centres across the three main geographical regions in the KSA. Data went through duration of coding following qualitative data analysis framework based on Miles and Huberman's philosophical underpinnings.ResultsThe findings demonstrated that 89.5% (n = 17) of the MRI departments surveyed rely on the service provided by the equipment vendor in order to ensure ongoing MR scanner performance. Overall, the level of MR radiographer participation in weekly MR scanner QA testing was low (13.3%, n = 3). Lack of legal requirement, professional organisation and knowledge were highlighted as the principal factors limiting radiographer involvement in the weekly MR QA in the KSA.ConclusionThe results of this study support the establishment of a legal requirement and national policy in order to encourage radiographers in the KSA to take an active role in MRI QA testing to enable suboptimal MR scanner performance to be identified before it becomes clinically evident.     

Common medical ethics dilemmas: Few reflections from a Saudi perspective

Medical ethics plays a crucial role in physicians’ daily practice, as it reflects on themselves, their institution, and, most importantly, the outcome of the treatment they provide to their patients. Common medical ethics dilemmas faced in Saudi Arabia include: end-of-life care, patient rights, which comprise autonomy, informed consent, and confidentiality, reproductive ethics, and equity of resources. The identification of flaws within the healthcare system and the implementation of clear guidelines are important to overcome the risk of malpractice and flawed judgment, and ensure the delivery of the best possible care to patients.     

Abusing female children by circumcision is continued in Egypt

Female circumcision is a frank picture of female child abuse that is practised widely in many countries especially in Africa. This procedure is considered a fundamental violation of human rights. The procedure is expected to be declining in Egypt in response to the recent medicolegal litigation in 2007. The aim of this study is to record the prevalence of female circumcision in 2010, in the region of Cairo and Giza, seeking to show if there is difference in the practice after the change in the law and banning of the procedure. A formatted questionnaire for 244 female volunteers was conducted. Statistical analysis revealed that 63.9% of the sample had been victimised by circumcision. The mean age of circumcision was 10.846±1.98 years. Circumcision took place at victim's home in 56.5%, private clinics in 38.5% or at hospitals in 5%. The procedure was performed by medical personnel in the majority of cases. The motivation behind the practice was primarily traditional beliefs (64.1%) followed by religious considerations (35.9%). Experienced complications were emotional trauma in 94.9%, haemorrhage in 33.3% and dysuria in 7.7%. Sexual problems were exclusively reported by the victimised subjects in 72.7% of sexually experienced subjects.     

A study of suicides in Kildare, 1995-2002

This paper focuses on 109 cases of suicide that occurred in Kildare from 1995 to 2002. These statistics were obtained by examining the records of the Kildare County Coroner. There is no central national location for the records of the 48 coroner jurisdictions in Ireland and all coroners are required by law to retain the files on each inquest indefinitely. However, the actual record of verdict given at inquest is not the one used for determining the suicide rate in the country. This is achieved by the Central Statistics Office (CSO) Form 104, which asks for the investigating police officer to give his or her opinion as to the cause of death. This results in discrepancies between what the coroner records and what the official suicide rate is presumed to be. These figures are further influenced by some coroners choosing to return a verdict "death in accordance with the medical evidence" as opposed to a verdict of suicide. The files were also examined to find the high-risk groups or those groups which have a tendency towards suicide. Over 84% of suicides were male and 32 men were between the ages of 20 and 30. It is suggested that the standardisation of recording verdicts of suicide be implemented as soon as possible as the current situation leads to variances between coroner's records and those kept by the CSO.     

Physician complicity in human rights violations: Involuntary sterilization among women from Mexico and Central America seeking asylum in the United States

Involuntary sterilization is a violation of human rights and grounds for asylum in the United States. Forensic medical evaluations can be useful in documenting this form of persecution and supporting asylees’ claims for immigration relief. We conducted a retrospective case analysis of the personal and medical affidavits of 14 asylum-seeking women from four Latin America countries who all reported they had been involuntarily sterilized. Sixty-four percent said that “consent” was coerced; the remainder were unaware of having been sterilized at the time of the procedure. In all cases, findings on hysterosalpingogram were consistent with sterilization, revealing that all 14 had undergone a tubal ligation. Eighty-six percent of the women had been sterilized at the time of childbirth. The healthcare providers involved in the 14 cases failed to obtain informed consent, misled patients about sterilization, engaged in discriminatory behavior, and/or breached patient confidentiality regarding their HIV-status. All 14 asylum cases were defensive; of the 7 cases (50%) that have been decided to date, 100% have been granted asylum.     

Feasibility of using ultrasound in ambulances in Saudi Arabia

BACKGROUNDIn developed countries, the economic feasibility of using ultrasound in ambulances before arriving at the hospital has been achieved through comprehensive studies, and this of course does not apply to Arab countries, as there are no current studies to support this. Therefore, this study is a preliminary measure of the economic feasibility of using ultrasound in ambulances in Saudi Arabia.AIMTo measure the demand for ultrasound equipment in ambulances in Saudi Arabia.METHODSA cross-sectional study of five different groups of participants including radiation technologists, emergency physicians, paramedics, Red Crescent managers and the public. Email and social media were used to deliver a questionnaire to these groups. The questionnaire included specific questions to measure the purpose of ultrasound use in each group of participants.RESULTSEach group had some knowledge on ultrasound and its benefits. More than 50% in each study group supported the availability of ultrasound in ambulances. Additionally, 60% of emergency physicians reported that they had difficulties in venous access, checking the presence of internal bleeding, recognizing pregnancy in trauma cases, and inserting endotracheal tubes, and the majority of them confirmed the effective role of ultrasound in achieving such tasks. Almost all paramedics (93.33%), physicians (98.89%), and Saudi Red Crescent managers (96.3%) emphasized the importance of communication between ambulance staff and emergency departments. Moreover, most physicians (77.78%), and technologists (82.73%) supported the presence of paramedics in ambulances to operate ultrasound in order to improve patient outcomes.CONCLUSIONMost of the study groups evaluated had knowledge on ultrasound and supported the presence of ultrasound devices in ambulances.     

Do written consent forms provide medicolegal protection from litigation in radiotherapy?

Two methods were used in an attempt to determine whether written consent forms serve a useful medicolegal purpose in Australian radiotherapy departments. First a survey was posted to all practising radiation oncologists to ask about their use of written consent forms and whether they had ever been useful in any claims made against them. Second, the largest medical defence organization in Australia was contacted for de-identified details about every claim ever made against a radiation oncologist. The survey yielded a response rate of 50.3%. Only one respondent indicated that any consent form had ever played a role in any claim and was not prepared to discuss it. Many radiation oncologists did not routinely use a consent form and its use could not be considered standard practice. The submitted consent forms generally did not contain warnings to the patient about specific risks of treatment. The details of the previous claims provided by the medical defence organization indicated that more often claims arose from circumstances in which a written consent form could not provide any useful protection such as radiation dose calculation errors. The medicolegal value of written consent forms in radiotherapy seems low, although further research may be necessary before dispensing with them completely.     

Medicolegal training in radiology; an overlooked component of the non-interpretive skills curriculum

ObjectiveRadiologists comprise approximately 3.6% of US physicians while ranked 6th–8th in medicolegal claims. Studies suggest that by the age of 60, about half of all radiologists will be sued at least once. Given this likelihood, it is surprising how little attention is paid to teaching of medicolegal issues. It is hypothesized that most trainees emerge from residency with only a vague notion of the medicolegal issues inherent in radiology.MethodsAll of the radiology attendings, trainees and alumni in our tertiary care teaching hospital were surveyed via an electronic questionnaire. Respondents were surveyed on overall knowledge of job-related medicolegal issues and willingness to receive additional education. The survey also included two real life medicolegal scenarios and the radiologists were asked to choose the most likely outcome.ResultsA questionnaire was sent to total of 359 trainees, attendings and alumni. There were 168 responses, constituting a 46.7% response rate, F:M 48:112. Only 41% of the respondents were aware that by the age of 60, half of them would be involved in at least one lawsuit. All knew the most common causes of malpractice claims; however, one-fourth were not aware of available medicolegal resources offered by radiological organizations; 85% of the respondents expressed willingness to attend medicolegal CME courses. All residents surveyed believed that medicolegal lectures should be included in their didactics.ConclusionThere is a dearth of knowledge among radiologists on job-related medicolegal topics. This survey suggests that incorporating additional medicolegal topics into the non-interpretive skills curriculum of residents and medicolegal CME for graduates would be well received.     

Malpractice claims in interventional radiology: frequency, characteristics and protective measures

Purpose

The use of interventional radiology procedures has considerably increased in recent years, as has the number of related medicolegal litigations. This study aimed to highlight the problems underlying malpractice claims in interventional radiology and to assess the importance of the informed consent process.

Materials and methods

The authors examined all insurance claims relating to presumed errors in interventional radiology filed by radiologists over a period of 14 years after isolating them from the insurance database of all radiologists registered with the Italian Society of Medical Radiology (SIRM) between 1 January1993 and 31 December 2006.

Results

In the period considered, 98 malpractice claims were filed against radiologists who had performed interventional radiology procedures. In 21 cases (21.4%), the event had caused the patient’s death. In >80% of cases, the event occurred in a public facility. The risk of a malpractice claim for a radiologist practising interventional procedures is 47 per 1,000, which corresponds to one malpractice claim for each 231 years of activity.

Discussion

Interventional radiology, a discipline with a biological risk profile similar to that of surgery, exposes practitioners to a high risk of medicolegal litigation both because of problems intrinsic to the techniques used and because of the need to operate on severely ill patients with compromised clinical status.

Conclusions

Litigation prevention largely depends on both reducing the rate of medical error and providing the patient with correct and coherent information. Adopting good radiological practices, scrupulous review of procedures and efficiency of the instruments used and audit of organisational and management processes are all factors that can help reduce the likelihood of error. Improving communication techniques while safeguarding the patient’s right to autonomy also implies adopting clear and rigorous processes for obtaining the patient’s informed consent to the medical procedure.     

Forensic medicine in the Rivers State of Nigeria: experience in four rural general hospitals

A retrospective study of 375 consecutive medicolegal cases seen in four peripheral general hospitals in the Rivers State of Nigeria over a five-year period (March 1984 to February 1989) was undertaken. The most common indications for forensic medical consultation were assaults (78.6%) using clubs, sticks, fists and machetes as weapons, road traffic accidents (9.1%) and sexual offences (7.7%). The proportions of accidental deaths (4.3%), homicidal deaths (2.9%), sudden natural deaths (0.5%), maternal deaths (0.5%) and suicidal deaths (0.3%) were much lower. The male-to-female ratio was 1.4 to 1. The patients' ages ranged from 10 months to 75 years, with a mean of 31.6 years. Twenty-three cases (6.1%) were children, while the remaining 352 cases (93.9%) were adults. The study showed that for those cases which do come to the pathologist's attention, forensic personnel and laboratory services are inadequate in the peripheral parts of Nigeria. The study also highlighted the possible range of medicolegal problems of which the medical practitioner should be aware, even if he is practising in the rural non-urbanized areas of Nigeria. The study shows that not all deaths are registered in Nigeria.     

Begutachtung behaupteter letaler Behandlungsfehler im Fach Rechtsmedizin

The results of a multicentre study authorised by the German Federal Ministry of Health regarding the expert opinion of alleged lethal medical malpractice are presented in this article. The main results of this study were: in the cooperating institutes the total number of autopsies due to suspected medical malpractice ranged between 1.4 and 20%. In more than 40% of cases preliminary proceedings were started because the manner of death was characterised as “not natural” or “not clarified”, which affected more hospital doctors than doctors in private practice. However, the number of confirmed cases of medical malpractice was clearly higher for doctors in private practice than for hospital doctors. Surgery was still at the top of the disciplines involved in medical malpractice claims but the number of confirmed cases was below the average. Mistakes in care were confirmed to be above the average. The efficacy of medico-legal expert opinion is demonstrated by the fact that 2,863 out of 4,450 cases could be clarified by autopsy.