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Malpractice claims in ophthalmology: a 10-year review/Oftalmolojide tibbi uygulama hatalari: 10 yillik veriler.

Introduction

The frequency of ophthalmologic events resulting in malpractice claims and the malpractice claims that are taken to the court process show various rates. (1-2) In the literature, there are a limited number of studies related to medical litigation in ophthalmology. (2-4) Most of the malpractice claims resolved out of the court and ophthalmologists were found at fault in rare cases. (3-5)

A review of the literature showed that cataract was the primarily reason (varies 1/4 from to 1/2) among ophthalmologic conditions involving malpractice claims. (1-7) In a study based on the data of the National Health Service of England for the period 1995 to 2006, ophthalmology claims accounted for 2.5% of the total malpractice claims, and cataract treatment was found as the leading cause of the claims. (1) A study conducted in Spain considered that most of the claims were rebutted or resolved out of the court and found no criminal case. (6) Tomkins stated that 1/3 of the claims resulted in a settlement. (5)

The organization whose expert opinion for medical malpractice claims is requested by legal authorities (judges, prosecutors) in Turkey is the Supreme Health Council (SHC), affiliated with the Ministry of Health. The SHC is an official body like National Health Services whose expert opinion needs to be taken in claims related to criminal law suits and also action for compensation. The SHC examines medical records sent by legal authorities and gives expert opinion. (8,9)

In the present study, we aimed to reveal and discuss the profile of medical malpractice claims and liability of clinicians involved in ophthalmology cases in adults and children reported to the SHC. We reviewed the expert opinions related to malpractice claims and formed a database to reveal medical litigation in ophthalmologic cases.

Materials and Methods

Expert opinions related to malpractice claims to the SHC were retrospectively reviewed. Out of 1531 malpractice claims reported by the SHC of Turkey between the years 1991-2000, 59 (3.85%) were related to ophthalmology. Data including patients' age, sex, diagnoses, malpractice claims of judgment, distribution of ophthalmologic subspecialties, types and results of surgical/medical interventions, whether sequel/death occurred or whether autopsy was performed, expert opinion of claims, and the distribution of liability of health workers in these reports were collected. The data obtained were evaluated by using SPSS 15.0 statistics program.

Results

We reviewed 59 (3.85%) cases among 1531 malpractice claims reported by the SHC of Turkey between 1991 and 2000. We excluded two cases because of limited medical records and medicolegal reports reviewed. Remaining 57 cases had a mean age of 26.46 [+ or -] 20.35 years (range: (2-74 yrs), and 63.6% were male.

Of the cases, 78.7% resulted in crime lawsuits. More than half of the (58%) ophthalmologic events tend to malpractice claims occurred in the three biggest cities of Turkey.

Most frequently encountered ophthalmologic events that resulted in malpractice claims were: cataract surgery ranked first with 19 malpractice claims (33.3%) followed by traumatic injuries of the eye (ophthalmologic emergencies) (15.8%), and preparing erroneous reports (15.8%). Manner of events that led to malpractice claims was classified as unintentional events, intentional events (interpersonal violence), disobeying legal responsibilities (preparing erroneous reports), and others (Figure 1).

Table 1 shows the distribution of malpractice claims brought into the court. Claims referred to the court were determined according to the Penal Code.

All of the cases brought into the court related to forgery of medical documenting and negligence of duty were found liable by expert opinion of the SHC.

As for the distribution of medical conditions involved in malpractice claims by ophthalmological subspecialties, 4 cataract surgery cases, 1 glaucoma surgery case, 2 trauma cases, 2 strabismus cases, 8 preparing false report cases, 2 oncology cases, 2 iatrogenic trauma cases, and one out of ophthalmology case were deemed to be at fault by the SHC. In cataract surgery treatment cases, allegations related to intraocular lenses (IOL) like selecting wrong type of lens, postoperative lens dislocation, endophthalmitis, retinal detachment, vitreous loss accounted for 16 of the cases.

Wrong side eye evisceration was performed in one case with the diagnosis of retinoblastoma.

Ophthalmologists were not found liable in the areas of oculoplastics, medical retina, vitroretinal surgery, uveitis, refractive surgery.

Figure 2 shows the distribution of outcomes of interventions according to ophthalmologic subspecialties. There was significant relation between ophthalmologic subspecialties and outcomes of interventions (p<0.05([x.sup.2] = 11.633; p = 0.020).

Of the cases, 36.8% was placed in private clinics or private hospitals. When the place of the event (private or official) was investigated: lack of care was mostly observed in state hospitals than in private ones (6 to 0 cases), and failure to obey the legal procedures was observed mostly in private clinics or private hospitals than in state hospitals (7 to 2 cases). ([x.sup.2] = 10.880; p=0.028) The health personnel was found faulty in 22 events, 11 of which occurred in private clinics or hospitals.

Figure 3 illustrates the distribution of health centers where the ophthalmologic events tended to malpractice claims by the expert opinion of the SHC. There was no significant relation between health personnel's liability and health centers.

Distribution of health personnel found liable by expert opinion of the SHC is shown on figure 4.

There was not any significant difference between health personnel occupational area and liability ([x.sup.2]=9.567; p=0.71) (Figure 4).

The SHC of Turkey decided the health professionals to be at fault in 22 claims (38.6%) but were not found liable in 35 claims (61.4%).

Near half of the surgical and medical interventions (14 of 48 cases) involved in malpractice claims were found at fault; however, most of the cases related to preparing reports were found faulty (8 of 9 cases). A significantly higher rate of health professionals were deemed to be at fault in preparing erroneous/ improper reports than in medical or surgical interventions. ([x.sup.2] = 12.032; p=0.02).

Distribution of outcomes of medical/surgical interventions is shown in Figure 5.

There was no significant difference in the outcomes of interventions between health centers (private clinics/hospitals or state hospitals).

Among 38 surgical procedures, 36 of them resulted in death or sequel, while among 10 medical procedures, 7 led to death or sequel. The outcome of intervention (death or sequel) did not differ significantly according to surgical or medical procedures. We investigated 22 health personnel found at fault: 10 events resulted in sequel and 3 events resulted in death, while the remaining 9 led to no sequel or death. Outcome of intervention (sequel or death) did not differ significantly whether the ophthalmologic health personnel found liable or not.

None of the cases in which regional anesthesia techniques was used resulted in death, while half of the cases that general anesthesia technique was used resulted in death ([x.sup.2] = 8.571, p=0.03). Among malpractice claims that were found faulty by the SHC, regional anesthesia or general anesthesia techniques did not differ significantly.

Medicolegal autopsy was performed on 6 of the cases which led to death among 8 cases (Figure 6).

Table 2 shows the distribution of causes of liabilities among ophthalmologists found by expert opinion of the SHC.

Discussion

Ophthalmology and subspecialties carry potential risks for health workers against malpractice claims. Improvements in surgical procedures could increase these risks. (4-6)

Research on epidemiology and etiology of malpractice lawsuits has been gaining importance. The risk of an ophthalmologist taken a place in a medical condition involving malpractice claim (being reported for a malpractice claim) arises. (6) In addition, every 100 obstetricians/gynecologists had 0.62-0.91 lawsuit per year, while every 100 ophthalmologists had the lowest lawsuits per year. (6-9)

Among cataract surgery claims, technical mistakes, postoperative infections, inadequate consent, fault in selecting intraocular lens size/type were found as common causes for cataract treatment claims. (2) In the present study, claims related to intraocular lenses in cataract surgery process were found the most popular claim.

Paid indemnities for malpractice suits have dramatically increased in recent years. (10) Verdicts decided by judgment favored the doctor in most of the malpractice suits, however most of the claims resolved before judgment process in ophthalmology. (3-5) In a study, the compensation ratios and amounts were evaluated and it was observed that although cataract surgery was the leading cause for compensation claims, most of the glaucoma cases resulted in payment.1 In the present study, cataract accounted for 5 out of a total of 9 compensation cases, consistent with the literature; however, we could not access the data about the paid indemnities for malpractice claims. High risk of cataract surgery and high number of surgeries may have resulted in this outcome.

It was stated that many ophthalmology claims could be observed with diabetic claims. (3) We had only one case with cataract due to DM, in which optic atrophy occurred. Unlike from the literature, we could not discuss the DM-related cases because they might be classified under other clinical branches like internal medicine and were not included in this study.

The claim for cornea transplantation without any consent of the family was found as a correct intervention because of the legislation that permits cornea transplantation without consent of the deceased family. This finding provided us the importance of obeying legislations about organ transplantation.

The majority of incidents in our study occurred in state hospitals (56.1%), however, only 28.1% of clinicians in these hospitals were found to be liable. The large number of such claims in state hospitals could be associated with the fact that most of the ophthalmologists are working in state hospitals in our country, exceeding the number of those of private hospitals, clinics, and university hospitals.

Lack of care was mostly observed in state hospitals than in private ones (6 to 0 cases) and failure to obey the legal procedures was observed more frequently in private clinics or private hospitals than in state hospitals (7 to 2 cases). In our study, there was one case of wrong side eye evisceration, and no similar data was detected in the literature.

The leading cause of medical errors was reported to be misdiagnosis, recklessness, insufficient experience in Turkey.9-11 Unlike from the literature, in the present study, failure to obey legal legislations and lack of care and attention (recklessness) in operative period was found as the main reasons of liabilities.

Every malpractice claim resulting in death must have gone to autopsy, however, our findings showed contrast data. (12,13) Autopsy was performed in 3 (37.5%) of the cases which resulted in death. Lack of medicolegal evaluation in these cases could lead to another malpractice claim.14-17

In Turkey, the regulations adopted in 2004 allow the plaintiffs and defendants to resolve their conflict themselves before judgment. This study revealed that all of the cases involving the claims of judgment related to forgery of documenting and negligence of duty were found liable by expert opinion and found guilty at the end of the juridical process.

Sharing/revealing data related to medical malpractice claims by health personnel could prevent faults at similar medical conditions. (15-19) For the purpose of solving problems around the standard expert opinion evaluations, legislations of malpractice events should be put into practice and specified judgment system (expert courts) could be established.

DOI: 10.4274/tjo.83584

References

(1.) Nadeem A. A decade of clinical negligence in ophthalmology. BMC Ophthalmology. 2007;7:20.

(2.) Bettman JW Seven hundred medicolegal cases in ophthalmology. Ophthalmology, 1990;97:1379-84.

(3.) Mavroforou A, Michalodimitrakis E. Physicians' liability in ophthalmology practice. Acta Ophthalmol. Scand. 2003;81:321-5.

(4.) Wasfy IA, Wasfy EI, Aly TA, Abd-Elsayed AA. Ophthalmic medicolegal cases in Upper Egypt. Int Arch Med. 2009;2:1.

(5.) Tomkins C. Over 120 years of defending ophthalmologists. Br J Ophthalmol 2006;90:1084-5.

(6.) Menendez-De-Lucas Ja, Luque-Mialdea F, Molina-Seoane V Ophthalmology complaints in Spain. Arch Soc Esp Oftalmol. 2009;84:459-68.

(7.) Kraushar MF, Robb JH: Ophthalmic malpractice lawsuits with large monetary awards. Arch Ophthalmol. 1996;114:333-7.

(8.) Ozdemir MH, Cekin N. The structure and the duties of the supreme council of health. The Bulletin of Legal Medicine (in Turkish). 1998;1:94-7.

(9.) Ozdemir MH, Ergonen TA, Can IO. Medical malpractice claims involving children. Forensic Sci Int. 2009;191:80-5.

(10.) Studdert DM, Mello MM, Gawande AA, et al. Claims, errors and compensation payments in malpractice litigation. N Engl J Med. 2006;354:2024-33.

(11.) Ozdemir MH, Cekin N, Can IO, Hilal A. Malpractice and system of expertise in anaesthetic procedures in Turkey. Forensic Sci Int. 2005;153:161-7.

(12.) Madea B. Medico-legal autopsies as a source of information to improve patient safety. Leg Med (Tokyo). 2009;11 Suppl 1:S76-9.

(13.) Bove KE1, Iery C; Autopsy Committee, College of American Pathologists. The role of the autopsy in medical malpractice cases, II: controversy related to autopsy performance and reporting. Arch Pathol Lab Med. 2002;126:1032-5.

(14.) Featherstone T Risk management, adverse events and litigation in vitreoretinal surgery. Clin Risk. 2007;13:7-11.

(15.) Kuehm SL, Doyle MJ. Medication errors: 1977 to 1988. Experience in medical malpractice claims. N J Med. 1990;87:27-34.

(16.) Bhan A, Dave D, Vernon SA, Bhan K, Bhargava J, Goodwin H; Medical Defence Union; Medical Protection Society; Medical and Dental Defence Union of Scotland. Risk management strategies following analysis of cataract negligence claims. Eye (Lond). 2005;19:264-8.

(17.) Ali MN, Fraser SG. Medicolegal aspects of glaucoma. Clin Risk. 2007;13:12-6.

(18.) Demircan A, Yukseloglu H, Erkan I, Gul E, Altan T, Elmas I. Goz hekimlerinin kornea nakli surecinde karsilastiklari tibbi, hukuki ve etik sorunlara yaklasimlarinin degerlendirilmesi. Turkiye Klinikleri J Med Sci. 2012;32:382-8.

(19.) Ozdemir MH, Saracoglu A, Ozdemir AU, Ergonen AT. Dental malpractice cases in Turkey during 1991-2000. J Clin Forensic Med. 2005;12:137-42.

Mehmet Hakan Ozdemir, Ismail Ozgur Can, Nilufer Kocak *

Dokuz Eylul University School of Medicine, Department of Forensic Medicine, Izmir, Turkey * Dokuz Eylul University School of Medicine, Department of Ophthalmology, Izmir, Turkey

Address for Correspondence/Yazisma Adresi: Mehmet Hakan Ozdemir MD, Dokuz Eylul University School of Medicine, Department of Forensic Medicine, Izmir, Turkey Phone: +90 232 412 28 54 E-mail: hakan.ozdemir@deu.edu.tr Received/Gelis Tarihi: 12.04.2013 Accepted/Kabul Tarihi: 30.07.2013

Table 1. Distribution of malpractice claims according to
laws by judgment

                                          Claims found liable
Claims referred                           by expert opinion
to the court                 n    %       of the SHC (n)        %

Forgery of medical           5    8.8     5                     100%
documenting and records
(improper/ erroneous
reporting)

Negligence of duty           6    10.5    6                     100%

Bodily injury due to lack   28    49.1    7                     25%
of care, attention, and
insufficient experience

Leading to death             7    12.3    2                     28.5%

Unauthorized cornea          2    3.5     0                     0.0%
transplantation

Claim for damages            9    15.8    2                     22.2%
(compensation)

Total                       57    100     22

Table 2. Distribution of liabilities by expert opinion of the SHC

                  Number of
                  decisions (n)   Causes of liabilities

PREOP. PERIOD     4 (19%)         Lack of monitoring before surgery
                                  Failure to take informed consent
                                  Selection of wrong drug treatment

PEROP. PERIOD     5 (24%)         Lack of care and attention
                                  Selection of wrong drug treatment
                                  Unskillfulness in surgery
                                  Negligence of treatment

POSTOP. PERIOD    2 (9%)          Deficient monitoring

OTHER             11 (48%)        No consultation to specialist
                                  Preparing erroneous/
                                  improper reports

Figure 2. Distribution of outcomes of interventions
by ophthalmologic subspecialties

                      Functional losses    Death

Cataract surgery             17              1
Glaucoma care                 4              0
Strabismus surgery            1              3
Trauma                        7              2
Others *                      6              2

* Oncology ocular emergencies out of ophthalmology

Figure 3. Distribution of Expert Opinion by the Health
Centers and the State of Liability

                       Claims    At Fault

State Hospital           32         9
Private Hospital         12         6
Private Clinics           9         5
University Hospital       4         2

Figure 4. Distribution of health personnel that were found
liable by SHC expert opinion

                                Health personel   Faulty

Opthalmologist                        34            15

Opthalmology assistant                 3            2

Ophtalmologist & anaosthosia          13            2

Others *                               7            3

* Others; pediatrician & ophthalmologist, general
practitioner, hospital director

Figure 5. Outcomes of medical/surgical interventions

Loss of vision       25
Decrease in vision   10
Death                8

Figure 6. Distribution of files found liable by deaths and
state of medicolegal autopsy

total faulty                57    22

deaths faulty              8     3

autopsied deaths/faulty    6     3
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Title Annotation:Original Article / Ozgun Arastirma
Author:Ozdemir, Mehmet Hakan; Can, Ismail Ozgur; Kocak, Nilufer
Publication:Turkish Journal of Ophthalmology
Article Type:Report
Date:Jan 1, 2014
Words:2718
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