The number of complaints and claims made against healthcare providers is increasing, and these complaints lead, in turn, to a higher number of medical disputes, with surgery being one of the specialties most commonly involved in such disputes.1,2 Medical disputes arise from medical errors or malpractice, and miscommunications between patients and hospital staff are also a major factor. Nevertheless, there is no denying that malpractice does exist and that there is always room to improve the quality of surgical care. To facilitate such improvement, a new specialty encompassing trauma, emergency general surgery, and surgical critical care has emerged under the nomenclature of acute care surgery (ACS). This restructuring of emergency surgical service has previously been shown to improve quality of care for American and British patients.3 In Australia and New Zealand, a binational surgical audit has been shown to reduce surgical mortality rates by as much as 30%.4 In Taiwan, however, the incorporation of ACS systems remains unpopular and no nationwide surgical audit has been implemented. As such, any discussions regarding surgical malpractice are limited to conference rooms in individual institutions.
In order to examine and identify the key points for improving the quality of surgical patient care in Taiwan, we focused in this study on the group of patients comprising those who are or have been involved in medical disputes. More specifically, we investigate disease etiologies and the scenarios in which surgery-related medical disputes might take place, in addition to further analyzing the causes and outcomes of such disputes.
The definitions of various terms in this study must be clarified. For instance, “medical malpractice” was defined as any act or error by a physician during treatment of a patient that deviated from the accepted norms of practice in the medical community and caused injury to the patient; “medical dispute” was defined as any case in which a patient asked (whether by means of a threat or a request for an apology or reimbursement) that the physician make up for a perceived treatment error, whether or not the given case involved actual medical malpractice; and “medical litigation” was viewed as any instance in which a patient filed a lawsuit against the physician over a medical dispute.5
In Taiwan, nearly all medical disputes that develop into cases of medical litigation are reviewed by the official witness examiner committee of the Department of Health. This committee provides a “medical assessment report” to help the judges or prosecutors to determine whether or not medical malpractice occurred. We extracted reports on all the surgery-related cases from this committee within 5 consecutive years (2004–2008).
These reports were reviewed retrospectively by three senior physicians from the emergency department who specialize in trauma and emergency general surgery in order to identify the background scenario, disease etiology, and possible cause of the medical dispute in each case. The causes of the various medical disputes were categorized under the following descriptions: “operation- or procedure-related complication,” “anesthesia complication,” “inappropriate management or decision,” and “delayed diagnosis or misdiagnosis.” In some cases, the cause could not clearly be ascribed to any of the above descriptions. So, in those cases, the cause of the dispute was considered to be “unsatisfactory result”, that is, the dispute was not related to malpractice. In our institution, review board approval was not required for this type of retrospective research.
A total of 154 cases were reviewed, of which 39 were trauma-related and 115 were disease-related (i.e., nontrauma cases; Fig. 1). Out of all 154 cases, the patient died in 97 cases (63.0%), while neurological sequalae occurred in 14 cases (9.1%); such poor outcomes were considered to be the legal grounds upon which the patients sued (Table 1). The two leading causes of disputes in this review were found to be operation- or procedure-related complications (35.7%) and unsatisfactory results (31.8%), followed by delayed diagnoses or misdiagnoses, inappropriate management, and anesthesia complications (Table 2).
Of the 115 nontrauma cases, 61 (52.2%) involved the gastrointestinal and hepatopancreaticobiliary system, making diseases of that type the most common disease etiology (Table 3). Of all the nontrauma patients, 35 presented with the acute abdomen clinical scenario and underwent emergency surgical intervention. The most common causes of medical disputes in nontrauma cases were operation- or procedure-related complications (47.0%), followed by unsatisfactory results and, delayed diagnoses or misdiagnoses (Table 2). The mortality rate was 54.8% in the nontrauma cases, while 7.8% experienced irreversible neurological complications (Table 1). In the operation- or procedure-related complications group, hemorrhages were the most common complication (25.9%), followed by sepsis/infections (Table 4). In the delayed diagnosis or misdiagnosis group, the most common disease encountered was ischemic bowel disease, which accounted for four of the 24 cases. Only four patients were categorized into the inappropriate management group; notably, all four patients received a diagnosis of incarcerated hernia, and three (75%) of those patients died.
In the 39 trauma-related cases, traffic accidents constituted the most common etiology (61.5%), followed by falls from a great height (including suicidal and accidental incidents) and assaults (Table 3). Unsatisfactory results were the most common cause of medical disputes in trauma cases (46.2%), followed by inappropriate management, and delayed diagnoses or misdiagnoses (Table 2). Mortality was the result in 87.2% of the trauma-related cases, while 12.8% of those patients suffered from irreversible neurological complications. In addition, men comprised the vast majority of the trauma-related patients (Table 1). Further analysis of the unsatisfactory result group showed that 13 out of those 18 patients died due to natural courses of their severe head injuries. It is also worth noting that eight of the 10 cases in the inappropriate management group received suboptimal hemorrhagic shock control and that all eight of those patients died. Meanwhile, six of the nine cases in the delayed diagnosis or misdiagnosis group suffered a bowel perforation or ischemia that was missed during an initial survey. All six of those patients later received surgical intervention but eventually died of peritonitis and sepsis. In contrast to the nontrauma series, only one patient from the trauma series who sustained an esophageal perforation after C-spine instrumentation was categorized into the operation- or procedure-related complications group.
The most high-risk specialties in Taiwan are obstetrics and gynecology, anesthesiology, and surgery.6–8 With people gradually starting to claim that their medical rights are similar to their consumer rights, all medical specialties should pay greater attention to medical disputes instead of looking only at medical malpractice. A study conducted by Sheetz et al9 revealed that patients’ perspectives regarding care do not necessarily correlate with the incidence of mortality and morbidity after major surgery. A cohort from Japan showed that medical disputes can occur even in cases in which there was no negligence and that these disputes may have costly consequences. Not only can the actual presence of medical errors cause serious medical disputes, but patients’ perceptions of miscommunication, especially in cases with a non-negligent adverse event, can also result in such disputes.10
Unsatisfactory results were the leading cause of medical disputes in the trauma group (46.2%), and were the second most common cause in the nontrauma group (27.0%), as noted in Table 2. We could not, however, identify any component of malpractice in our review of these cases. It is reasonable to assume that there must have been some miscommunication between the healthcare providers and patients and/or their family members in such cases. With advances in healthcare-related science and technology, patients always have optimistic expectations for treatment, so physicians are increasingly being called upon to answer for any results that fail to meet patients’ expectations. Mukherjee et al11 have reported that, overall, trauma surgeons encounter higher levels of patient dissatisfaction than do nontrauma surgeons; in addition to demonstrating a significant association between expression of such dissatisfaction and the risk of lawsuits.
The mean age of our entire patient group was significantly younger and the mortality and complication rates were significantly higher compared to patient groups reported previously.12 The patient group in this study is certainly not representative of the general population of Taiwan. Some cases involving minor defects in service or those with evident mistakes might have been resolved before leading to a lawsuit. All of the data were collected from cases involving medical disputes that were actually subjected to an investigation, thus, the high mortality rate simply reflects the fact that this series comprised high-risk and mistreated patients. It is relevant that almost half of the patients in our study presented with an underlying condition of trauma or acute abdomen (74 of 154 patients, 48.1%), as both are now considered an essential component of ACS. In considering the trauma and nontrauma series considered together, we noted that 40 cases (26.0%) required emergency general surgery (EGS) intervention. EGS patients represent a unique population. Compared with nonemergency surgical patients, EGS patients face a disproportionate burden of medical errors, complications, and death. Several studies have demonstrated that patients undergoing EGS experience a significant increase in complications, intensive care unit resource requirements, and 30-day mortality.12–14
Emergency surgical procedures are an important target for quality improvement. Even in mature medical systems, errors still occasionally lead to patients’ deaths, with the initial assessment, resuscitation, and initial intervention phases being particularly prone to errors. In the previous literature, the most commonly reported causes of preventable/potentially preventable trauma deaths have been hemorrhage, organ failure, and airway management.15,16 Our study is consistent with those earlier findings: the major form of inappropriate management that we identified among trauma patients was inadequate hemorrhagic shock control. Notably, four patients from the nontrauma group with the diagnosis of incarcerated hernia were considered to have received inappropriate management at their initial hospital visit. Namely, the incarcerated bowel segments were reduced manually while their abdominal conditions were not given proper follow-up. As an elective operation, abdominal hernia repair should be a safe procedure with minimal mortality and morbidity risks. As an emergency operation, the morbidity rate of the procedure may rise significantly to 27%.17 The mortality rate of 75% found in our study far exceeded the rates reported in previous studies. Accordingly, it seems that healthcare providers, especially emergency medical staff, should be better educated regarding the appropriate treatment of incarcerated hernia. In such cases, prompt surgical consultation should be initiated.
Our study underscores the demanding and challenging role typically played by an acute care surgeon. Currently in Taiwan, the training period required to attend either surgery board examination or emergency medicine board examination is 4 years. These are the two specialties that form the major first-line workforce for management of trauma and EGS patients in Taiwan. Among these two specialties, < 6 months of the training courses involve working with a trauma team. There is a trend toward early fixation of subspecialty among surgical trainees in Taiwan. Most trainees choose their subspecialty immediately after completing their 2nd year of residency. Unfortunately, few trainees choose trauma as their subspecialty at this stage. It is possible that both a lack of training and a shortage of manpower among acute care surgeons have had negative impacts on the quality of care. ACS is an evolving concept that has yet to gain widespread popularity in the medical community in Taiwan. It has already been demonstrated, however, that the adoption of ACS systems may improve the quality of care for trauma and emergency surgery patients.18,19 As such, we believe that current residency training programs for surgeons and emergency medicine physicians should be modified to place greater emphasis on managing trauma and EGS patients. Also, we should seriously consider the incorporation of the ACS system in Taiwan.
Our study had several limitations. First, it was a retrospective review and only cases that involved medical disputes were included. Some of the case files we examined contained detailed clinical information, including vital signs, laboratory data, procedures, and surgical outcomes, while others merely contained the name of the disease and the date of mortality. Therefore, the effort to reduce the influence of limited data by statistical analysis limited the conclusions drawn from the data because there were too many missing variables. Second, the categories in which the medical disputes were grouped were determined on the basis of limited clinical patient information. For many of the cases, the reasons that triggered the medical disputes were complex, such that categorizing them in terms of a single reason may have oversimplified the actual situations. In order to reduce the influence of this problem, a committee of three senior physicians reviewed each case in the study. If more than one factor was considered, it was put to a vote between the three committee members to decide the one major factor behind the medical dispute. If more than one cause was described for each case, the data became more incomprehensible and unconvincing. Despite the limitations of the flawed data, we believe the conclusions are consistent with the experiences of daily practice and are of value in improving the quality of care, especially in sounding the alarm about pitfalls in treating hemorrhagic shock and emergency surgical patients.
Surgery- or procedure-related complications and unsatisfactory treatment results constitute the major causes of medical disputes in Taiwan. Most of these cases involve the field of ACS, so the establishment of an ACS system should be considered to improve patient care. The management of hemorrhagic shock and incarcerated hernia should be reinforced in future medical training. In order to avoid unnecessary medical legal litigation, thorough explanations are mandatory. To prevent or possibly reduce future disputes or claims, there is a strong need to improve communication between health care providers and patients or their relatives.
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