Investigation of
medical malpractices in the field of orthopedics and associating factors in the
cases referred to the legal medicine organization of Guilan province
Alireza Badsar 1*, Mehran Soleimanha 2, Noushin
Yousefi 3, Ehsan Kazemnezhad Leyli 4, Mani HasanBabaii 5
1 Department of Forensic Medicine, School of Medicine, Razi Hospital,
Guilan University of Medical Sciences, Rasht, Iran
2 Department
of Orthopedics, School of Medicine, Orthopaedic Research Center, Poursina
Hospital, Guilan University of Medical Sciences, Rasht, Iran
3 Forensic
Expert, General Department of Forensic Medicine, Guilan Province, Rasht, Iran
4 Department
of Biostatistics, School of Nursing and Midwifery, Road Trauma Research Center,
Guilan University of Medical Sciences, Rasht, Iran
5 General
Practitioner, Guilan University of Medical Sciences, Rasht, Iran
*Corresponding
Author: Alireza
Badsar
* Email: badsar@gums.ac.ir
Abstract
Introduction: Medical malpractice is a type of treatment that fails to reach the
standards of conventional medical treatment and as a result, the patient
suffers injury. In addition to affecting the health of individuals, medical
malpractice also has negative effects on the physicians’ personal and social
life. Studies show that despite advances in technology and medical sciences the
number of malpractice complaints is increasing, according to studies, the
highest count of malpractice complaints referred in the Legal medicine
organization in Iran has been done against orthopedic specialists, which
indicates the necessity of the present study.
Materials
and Methods: In this descriptive and retrospective study, all complaints of medical
malpractice in the field of orthopedics archived in the Legal Medicine
Organization during 1391-1396 was examined. The method of data collection was
through checklists and information gathered from the archived complaint files.
Results: Based on the findings of this study, from the beginning of 1391 to the
end of 1396, 67 complaints were registered about orthopedic surgery. 49
patients were male and 18 were female. 17 were single and the rest were
married. Of these, 40 patients were treated in public university centers, 10 in
non-university government centers, and 17 in private centers. Of surgeries 17
were emergencies and 50 were elective. The site of injury in 29 patients was
the upper limb and shoulder and 38 the lower limbs and pelvis. In total, out of
67 registered complaints, 38 were acquitted and 29 cases were found guilty of
medical malpractice.
Conclusion: Among the registered surgery complaints in the Legal Medicine
Organization of Guilan Province, the highest number of complaints were of
surgeries operated on male patients. In addition, the highest number of
complaints from married patients were related to cosmetic surgeries, elective
surgeries, and surgeries performed in public university centers. More than 50%
of the verdicts issued, held the practitioner responsible for medical
malpractice. Malpractice verdicts had no significant correlation with the
variables that were observed in this study
Keywords: General surgery, Forensic medicine, Malpractice complaints
Introduction
According to the
definitions, medical malpractice is a treatment that has not been done
following the standards of conventional medical treatment, and as a result, the
patient suffers physical injury, disability, or death (1). In addition to the devastating effects
that medical malpractice has on the health of individuals in society, it can
also have negative effects on the personal, familial, social, and professional
lives of medical staff. These effects can range from psychological trauma and
substance abuse to suicide.16 Some physicians have even considered
well-resolved complaints as one of the most traumatic experiences of their
lives (2). Another detrimental consequence
of medical malpractice is the formation of “defensive medicine”, in which
physicians, due to the threat of malpractice complaints, deviate from standard
medical treatment, and seek unnecessary counseling and testing, which disrupts
the trust between doctor and the patient and imposes great costs on the health
system and the patient. Unfortunately, despite the negative consequences of
medical malpractice on the health of individuals in society and the personal
and professional life of medical staff, physicians and others involved in the
treatment of patients are not aware of or have insufficient information about
forensic medicine in which one of the most important topics is medical
malpractice, especially malpractice that leads to death.
Whenever any of the stages
of timely diagnosis, examination, treatment, follow-up, and counseling is not
done according to the accepted medical standards and principles, the doctor has
committed medical malpractice.
It is worth mentioning
that in some cases, despite all the appropriate measures, diagnosis or the
treatment is not completed properly, in which case the doctor has not committed
any negligence (3-5).
To judge the incidence or absence
of medical malpractice, the following should be considered: the physician must
have accepted responsibility for the treatment of the patient and the patient
must have suffered damage due to failure to comply with the technical and
scientific standards (6). On the other hand, it should be
noted that in spite of the physician’s high skills and knowledge in his field
of specialization, and the treatment’s compliance with scientific, technical,
and ethical standards, in some cases it is still possible that the treatment
won’t lead to the desired results. Also, it should be added that not all
physicians have the same knowledge (7).
According to studies,
international reports indicate that, unfortunately, despite the recent
developments in technology and medicine, the number of complaints against
physicians is increasing (8). Studies conducted in Iran are
also consistent with international studies. Several studies conducted in Iran
have shown that the highest number of medical complaints referred to the
Forensic Medicine Commission is related to orthopedics (9). The aforementioned problems led
us to conduct the present study.
Materials and Methods
In this descriptive
and retrospective study, after obtaining permission from the ethics committee
of Guilan University of Medical Sciences and making the necessary coordinations
with the forensic medicine department of Guilan University of Medical Sciences,
all cases of medical malpractice complaints in orthopedics in the General
Directorate of Forensic Medicine of Guilan Province from the beginning of 1391
to the end of 1396 were reviewed.
The method of data
collection was checklists using the files in the Medical Commission of the
General Directorate of Forensic Medicine of Guilan Province. The checklist used
included the patient's age, sex, and marital status, type of medical center,
location of the injury, type of surgery, causes of negligence, the way they
were informed of the malpractice, verdict issued, and injuries caused by
medical negligence. After collecting file information through a study
checklist, the data were entered into SPSS software version 21 and analyzed
through appropriate statistical methods.
To comply with medical
ethics and confidentiality of information, the names and surnames of the
plaintiffs and their addresses were not registered.
Results
Based on this study, from
the beginning of 1391 to the end of 1396, 67 cases of orthopedic surgery
complaints were referred to the Forensic Medicine Organization of Guilan
Province. Of these, 49 cases were related to male patients and 18 cases were
related to female patients. Out of 67 cases reviewed, 29 cases were found
guilty of medical malpractice. In 38 cases, the doctor was acquitted. None of
the cases were terminated due to the patient's consent or conciliation.
The
age range of patients in complaint files ranged from a minimum of 2 years to a
maximum of 77 years, and most patients were between 40 and 59 years old. The
mean age of patients in the current study was 39.67 and the standard deviation
was 19.20.
Among
the studied cases, 40 patients (59.70%) were operated in public university
centers, 10 patients (14.9%) in non-university government centers, and 17
patients (25.3%) in Private clinics. none of the patients underwent surgery at
charity medical centers.
50
out of 63 cases of complaints were related to elective surgeries and only in 17
cases (25/3%), surgery was performed as an emergency.
The
highest number of injuries due to medical malpractice was present in the lower
extremities and pelvis in 21 cases, followed by the upper extremities and
shoulders in 17 cases. In none of the cases were there any complaints of spinal
injuries.
Also,
most of the injuries caused by medical malpractice were malunion (18),
restriction of movement (16), and surgical site infection (9).
Most
causes of malpractice were related to negligence in practice in 18 cases
followed by carelessness in practice in 7 cases.
The
percentage of malpractice by gender in the reviewed cases was 51% in male
patients and 22% in female patients, which was statistically significant (P =
0.035) (Table1, 2 and 3).
Table 1. Frequency distribution based on
demographic characteristics and malpractice information.
|
|
Individual Variables |
Frequency |
Percent |
|
Age |
<20 |
12 |
17.91 |
|
20-39 |
20 |
29.85 |
|
|
40-59 |
27 |
40.30 |
|
|
>60 |
8 |
11.94 |
|
|
Mean
value ± Standard deviation |
Least |
Most |
|
|
39.67 ± 19.20 |
2.00 |
77.00 |
|
|
Sex |
Male |
49 |
73.13 |
|
Female |
18 |
26.87 |
|
|
Marital
status |
Single |
17 |
25.37 |
|
Married |
50 |
74.63 |
|
|
Medical
center |
Public
educational |
40 |
59.70 |
|
Public non-educational |
10 |
14.93 |
|
|
Private |
17 |
25.37 |
|
|
Site
of injury |
Upper
extremities and shoulders |
29 |
43.28 |
|
Lower
extremities and pelvis |
38 |
56.72 |
|
|
Type
of surgery |
Emergency |
17 |
25.37 |
|
Elective |
50 |
74.63 |
|
|
Cause
of malpractice* |
Negligence |
18 |
64.29 |
|
Carelessness |
7 |
25.00 |
|
|
Non-compliance
with government systems |
1 |
3.57 |
|
|
Lack
of skill |
1 |
3.57 |
|
|
A combination
of the above |
1 |
3.57 |
|
|
Information
of malpractice |
By
doctors and other specialists |
26 |
38.81 |
|
By other
individuals |
41 |
61.19 |
|
|
Verdict |
Not
guilty |
38 |
56.72 |
|
Guilty |
29 |
43.28 |
|
|
Injuries
caused by malpractice** |
Nonunion |
6 |
10.91 |
|
Malunion |
18 |
32.73 |
|
|
Movement
restriction |
16 |
29.09 |
|
|
Surgical site
infection |
9 |
16.36 |
|
|
Vascular
injury |
1 |
1.82 |
|
|
Amputation |
4 |
7.27 |
|
|
Systemic |
1 |
1.82 |
*Chi-squared test **Fisher's
exact test
Table 2. Frequency distribution of demographic characteristics based on cast
verdict.
|
|
Verdict |
P |
|||||||
|
Not guilty |
Guilty |
Sum |
|||||||
|
Freq. |
% |
Freq. |
% |
Freq. |
% |
|
|||
|
Age |
<20 |
6 |
50.0 |
6 |
50.0 |
12 |
100.0 |
0.596** |
|
|
20-39 |
10 |
50.0 |
10 |
50.0 |
20 |
100.0 |
|
||
|
40-59 |
18 |
66.7 |
9 |
33.3 |
27 |
100.0 |
|
||
|
>60 |
4 |
50.0 |
4 |
50.0 |
8 |
100.0 |
|
||
|
Sum |
38 |
56.7 |
29 |
43.3 |
67 |
100.0 |
|
||
|
Sex |
Male |
24 |
49.0 |
25 |
51.0 |
49 |
100.0 |
0.035* |
|
|
Female |
14 |
77.8 |
4 |
22.2 |
18 |
100.0 |
|
||
|
Sum |
38 |
56.7 |
29 |
43.3 |
67 |
100.0 |
|
||
|
Marital Status |
Single |
8 |
47.1 |
9 |
52.9 |
17 |
100.0 |
0.353* |
|
|
Married |
30 |
60.0 |
20 |
40.0 |
50 |
100.0 |
|
||
|
Sum |
38 |
56.7 |
29 |
43.3 |
67 |
100.0 |
|
||
Table 3. Frequency distribution of type of medical center, site of injury,
type of surgery, how to obtain information about malpractice, and injuries
caused by malpractice based on the issued verdict.
|
|
Verdict |
P |
||||||
|
Not guilty |
Guilty |
Sum |
||||||
|
Freq. |
% |
Freq. |
% |
Freq. |
% |
|||
|
Medical
center |
Public
educational |
21 |
52.5 |
19 |
47.5 |
40 |
100.0 |
0.405* |
|
Public non-educational |
5 |
50.0 |
5 |
50.0 |
10 |
100.0 |
||
|
Private |
12 |
70.6 |
5 |
29.4 |
17 |
100.0 |
||
|
Sum |
38 |
56.7 |
29 |
43.3 |
67 |
100.0 |
||
|
Site
of injury |
Upper
extremities and shoulders |
17 |
58.6 |
12 |
41.4 |
29 |
100.0 |
0.783* |
|
Lower extremities and pelvis |
21 |
55.3 |
17 |
44.7 |
38 |
100.0 |
||
|
Sum |
38 |
56.7 |
29 |
43.3 |
67 |
100.0 |
||
|
Type of
surgery |
Emergency |
10 |
58.8 |
7 |
41.2 |
17 |
100.0 |
0.839* |
|
Elective |
28 |
56.0 |
22 |
44.0 |
50 |
100.0 |
||
|
Sum |
38 |
56.7 |
29 |
43.3 |
67 |
100.0 |
||
|
Information
of malpractice |
By doctors
and other specialists |
0 |
0.0 |
26 |
100.0 |
26 |
100.0 |
<0.001* |
|
By other individuals |
38 |
92.7 |
3 |
7.3 |
41 |
100.0 |
||
|
Sum |
38 |
56.7 |
29 |
43.3 |
67 |
100.0 |
||
|
Injuries
caused by malpractice** |
Nonunion |
1 |
16.7 |
5 |
83.3 |
6 |
100.0 |
0.218** |
|
Malunion |
7 |
38.9 |
11 |
61.1 |
18 |
100.0 |
||
|
Movement restriction |
11 |
68.8 |
5 |
31.3 |
16 |
100.0 |
||
|
Surgical site
infection |
5 |
55.6 |
4 |
44.4 |
9 |
100.0 |
||
|
Vascular injury |
0 |
0.0 |
1 |
100.0 |
1 |
100.0 |
||
|
Amputation |
2 |
50.0 |
2 |
50.0 |
4 |
100.0 |
||
|
Systemic |
0 |
0.0 |
1 |
100.0 |
1 |
100.0 |
||
|
Sum |
26 |
47.3 |
29 |
52.7 |
55 |
100.0 |
||
*Chi-squared test **Fisher's exact test
Discussion
In the study of Adibzadeh et al. (1), Out of 135 cases
reviewed, 41 (30.37%) voted against malpractice, and 69.63% of the verdicts
were issued on the doctor's innocence, which is consistent with the present
study.
In the study of Karimi Nasab et al. (10), Out of 64 cases
reviewed, 49 cases resulted in medical malpractice (76.6%), and in 15 cases
(23.4%) physicians were acquitted.
In the study of Dr. Barzegar et al. (11) In 67.5% of the
studied cases, the doctor was found innocent and in 32.5% of the cases, the
doctor was guilty of medical malpractice.
In the study of Fallah Karkan et al. (12), out of 49 cases
against orthopedic specialists, in 41 cases (83.67%) the vote was to acquit the
suspect or prohibit prosecution, and only in 8 cases (16.32%), the vote was
medical malpractice.
In the study by King et al. (13), 42% of the
patients were male and 57% of the patients were female. Unlike the present
study, there was no significant difference between the sexes.
In the study by Adibzadeh et al. (1), 54.1% were male
and 45.6% were female. As can be seen in this study, there is also no
significant difference between the female and male sexes.
In the study of Karimi Nasab et al. (10), 76.6% were male
patients and 23.4% were female patients. This difference is statistically
significant.
In the present study, 73.13% of the cases were male
patients, and 26.87% of the cases were female which is consistent with the
findings of the study done by Karimi Nasab et al.
The percentage of malpractice in terms of age group
and marital status in the present study was not statistically significant.
In the study of Sadr et al. (14) 32.1% of the
complaints, which included 63 cases, were suggested by physicians and other
specialists, and 67.9% of the individuals were provoked to complain through
other individuals.
In the present study, the frequency of malpractice did
not correlate with either the medical center, location of the injury, or
injuries due to medical malpractice.
Conclusion
The case
outcomes of malpractices of patients who noticed suspicious practice through
other doctors and specialists were significantly more against the defendant
than those who were encouraged through other people; to such a degree that in
100% of the cases that malpractice was suggested by the practitioners, the
defendant was found guilty. While only 7.3% of cases that were encouraged
through other individuals were against the defendant. This finding is
statistically significant with P<0.001.
Suggestions
According
to the findings of the present study and the increasing trend of complaints
against physicians, it seems that there is a need for further research on
medical malpractice and complaints referred to forensic medicine. On the other
hand, it seems that the more familiar the physicians and other medical staff
are with the basics of forensic medicine and the individual and social
consequences of medical malpractice for the patient and the medical staff, the
less incidence of medical malpractice as a result of improvement and
standardization of the treatment process.
Author contributions
AB, MS, EKL, NY,
and MHB wrote and completed the
article. AB designed and edited the manuscript. All authors confirmed the final edited
version.
Conflict of interest
The authors declare that they have no conflicts of interest.
References
1. AdibZadeh A, Ghadi Pasha M, Pour Amiri A, Nakhaei N,
Samadi Rad B, Bastani M. A study on medical malpractices ending to death and
disability referred to Kerman Medical council’s medical malpractices
commission. J Forensic Med. 2012;6(20):141-54.
2. Nash L, Tennant C, Walton M. The psychological
impact of complaints and negligence suits on doctors. Australas Psychiatry.
2004;12(3):278-81.
3. Hickson GB, Federspiel CF, Pichert JW, Miller
CS, Gauld-Jaeger J, Bost P. Patient complaints and malpractice risk. JAMA.
2002;287(22):2951-7.
4. Wofford MM, Wofford JL, Bothra J, Kendrick SB,
Smith A, Lichstein PR. Patient complaints about physician behaviors: a
qualitative study. Acad Med. 2004;79(2):134-8.
5. Weng H-C, Steed JF, Yu S-W, Liu Y-T, Hsu C-C,
Yu T-J, et al. The effect of surgeon empathy and emotional intelligence on
patient satisfaction. Adv Health Sci Educ. 2011;16(5):591-600.
6. Yoo J, Chang C, Kang Y, Kim S, Seong S, Kim T.
Patient expectations of total knee replacement and their association with
sociodemographic factors and functional status. J Bone Joint Surg Br.
2011;93(3):337-44.
7. Bourne RB, Chesworth BM, Davis AM, Mahomed NN,
Charron KD. Patient satisfaction after total knee arthroplasty: who is
satisfied and who is not? Clin Orthop Relat Res. 2010;468(1):57-63.
8. Harmon G, Lefante J, Krousel-Wood M. Overcoming
barriers: the role of providers in improving patient adherence to
antihypertensive medications. Curr Opin Cardiol. 2006;21(4):310-5.
9. Raeissi P. Medical malpractice in Iran: A
systematic review. Med J Islam Repub Iran. 2019;33:110.
10. Kariminasab MH, Razavipour M, Ghaffari S,
Tofighi M, Zabihi M, Mohammadnezhad F. Investigating the Complaints of Patients
Against Orthopedic Surgeons in Mazandaran Province, Iran 2011-2014. J Maz Univ
Med Sci. 2017;27(152):192-6.
11. Barzgar Bafrouee A, Zarenezhad M, Gholamzadeh
S, Hosseini SMV, Gholi A, Gharedaghi J, et al. Evaluation of orthopedic
specialists’ malpractice complaints referred to Legal Medicine Organization from
2008 to 2010. J Forensic Med. 2016;22(1):55-66.
12. Fallah Karkan M, Badsar A, Amir Maafi A,
Heydarzadeh A, Rahbar Taramsari M. Survey on malpractice claims against
physicians judged in guilan medical council. J Guilan Univ Med Sci.
2014;23(91):8-15.
13. King JD, van Dijk PA, Overbeek CL, Hageman MG,
Ring D. Patient complaints emphasize non-technical aspects of care at a
tertiary referral hospital. Arch Bone Jt Surg. 2017;5(2):74.
14. Sadr S GM, Bagherzadeh A. Investigate cases of
medical malpractice in the field orthopedics at the Department of Forensic
Medicine in Tehran during the years 1998-2003. J Legal Med. 2008;46:78-86.