Malpractice and the Infectious Disease Any Physician WHAT YOU SHOULD KNOW! Why this talk? Why me?

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1 Malpractice and the Infectious Disease Any Physician WHAT YOU SHOULD KNOW! G.R. Donowitz 2015 Why this talk? Why me? Expert witness for a long time Defense and Plaintiff work Have said, No, no case and No, no defense equally Have experience but not necessarily respect for the interaction of the medical and legal professions Yes, I have been sued for medical malpractice and found innocent 1

2 Malpractice for the Internists Only thing we have to fear, is fear itself FDR, 1933 or not GRD, 2015 Goals of this session Define malpractice versus iatrogenic harm Review epidemiology of medical malpractice cases Review common themes that may get a good clinician in trouble Review what to do when a mistake is made 2

3 Malpractice: What is it? Malpractice : negligence + causation = harm Negligence: failure to provide reasonable care, departure from accepted norm failure to do what a reasonable physician would do in the same circumstance Causation: negligence directly or indirectly leading to a harmful outcome Malpractice: What is it? continued Harm: an outcome, more negative than expected given the patient s disease process Need all three components for malpractice Klaas,PB, Berge,KH, Klaas,KM, et al., Mayo Clin Proc: 2014:89:

4 Malpractice: What It Isn t Iatrogenic harm malpractice Iatrogenic (fr Greek): something that came to be because of a healer Klaas,PB, Berge,KH, Klaas,KM, et al., Mayo Clin Proc: 2014:89: Malpractice: What it is? 26 year old male with history of IVDA presents with sudden onset of fever, cough and pleuritic chest pain Physical exam: VS: T=38.8: R=26: P=110 dullness to percussion and BS on R WBC= 15,000; Hct= 43; plts=278,000 Thought to be drug seeking; D/C from ED with no further tests and Rx with Indocin Returns 2 days later in septic shock and dies: Dx: Bacteremic pneumococcal pneumonia 4

5 Malpractice: What it is? cont d Negligence: no recognition of SIRS: no CXR, no cultures, no antibiotics Causation: morbidity and mortality from untreated bacterial pneumonia in someone who more likely than not would have survived Harm: death All three criteria for malpractice met: case went to court, plaintiff s family won Malpractice: What it Isn t 56 year old male had emergency abdominal surgery for ruptured aneurysm Sponge left intra abdominally Three months later, had some discomfort, sponge was discovered as a? mass and subsequently removed No charge for subsequent work up, surgery, and no residual damage Surgeon sued 5

6 Malpractice: What it isn t cont d Negligence not really Causation: definitely Harm: not really Case went to court: defendant won Principles of Malpractice Court Rulings A civil case rooted in common law: must demonstrate a predominance of evidence not beyond a shadow of a doubt. More likely than not 51% 6

7 Medical Malpractice: How often Does It Occur 85,000 cases per year among internists and medical subspecialist 53.5%of claims go to litigation (vs 46.7% for anesth; 62.6% for Ob/gyn) Jena AB, Chandra A, Lakdawalla D, et al: Arch Intern Med:2012:172: Medical Malpractice: Outcome of Litigation Dismissal: 61.5% Resolved before a verdict: 33.3% Goes to a verdict: 2.7% Jena AB, Chandra A, Lakdawalla D, et al: Arch Intern Med:2012:172:

8 Medical Malpractice: Outcome of Litigation Of cases going before a verdict: 79.6% of judgments go to the defendant but it will take your time, your lawyer s time and therefore someone s money and will be a distraction A physician into whose life litigation comes is like a patient with an acute, unpleasant, yet survivable disease. 8

9 Why Do Internists Get Sued? Retrospective review of 369 internal medicine claims from : 58% related to diagnosis 23% related to treatment 9.5% related to medication management 2.2% related to errors in ordering 1.6% patient monitoring 5.7% misc. Doctor Company 2005 Malpractice due to Diagnosis 48 % cardiovascular (MI, PE, A fib, aneurysm) 31% neoplasm (delay in diagnosis) 9% infectious disease (failure to diagnose epidural abscess, osteomyelitis) Doctor Company

10 Malpractice in Infectious Disease: Personal Impressions Osteomyelitis: un healing skin wound or surgical site after months think osteomyelitis ESR, plain films, CT scans are non definitive Superficial swabs of the lesion are not helpful for underlying pathology MRI is the most sensitive radiologic procedure Malpractice in Infectious Disease cont d Epidural abscess: Numbness, extremity weakness, fecal/urinary incon nence, emergency surgery Uncontrolled pain surgery 10

11 Malpractice in Infectious Disease cont d Necrotizing fasciitis: pain out of proportion to physical findings systemic toxicity, gas in the tissues, crepitus are usually not seen, and when they appear, they are late findings there ae no definitive radiographic techniques LRINEC scoring system is helpful surgery is the only definitive means of making a diagnosis Wong C, Wang Y, Yon Kwang T, Curr Opin Infect Dis 2005:18: Malpractice in Infectious Disease cont d Necrotizing fasciitis: Morbidity and mortality is directly related to the amount of time it takes to do surgery 11

12 Malpractice: What To Do If You ve Made a Mistake First, take care of the patient, then talk to the patient and their family. Provide the factual information, let them know an investigation will occur to find out what happened. Don t be afraid to say I don t know Malpractice: What to do if you ve made a mistake cont d Do not do the following: abandon the patient say : you are overreacting, this happens all the time, I regret this mistake, If only I had.. 12

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