Well Leg Compartment Syndrome After Abdominal Surgery.

BACKGROUND: Well leg compartment syndrome (WLCS) is a complication to abdominal surgery. We aimed to identify risk factors for and outcome of WLCS in Denmark and literature. METHODS: Prospectively collected claims to the Danish Patient Compensation Association (DPCA) concerning WLCS after abdominal operations 1996-2013 and cases in literature 1970-2013 were evaluated. Cases of fasciotomy within 2 weeks after abdominal surgery 1999-2008 were extracted from the Danish National Patient Register (DNPR). RESULTS: There were 40 cases in DPCA and 124 in literature. In 68 % legs were supported under the knees during surgery. Symptoms of WLCS presented within 2 h after surgery in 56 % and in only 3 cases after 24 h. Obesity was not confirmed as risk factor for WLCS. The mean diagnostic delay was 10 h. One-third of fasciotomies were insufficient. The diagnostic delay increased with duration of the abdominal surgery (p = 0.04). Duration of the abdominal surgery was 4 times as important as the diagnostic delay for severity of the final outcome. DNPR recorded 4 new cases/year, and half were reported to DPCA. CONCLUSION: The first 24 h following abdominal surgery of >4 h' duration with elevated legs observation for WLCS should be standard. Pain in the calf is indicative of WLCS, and elevated serum CK can support the diagnosis. Mannitol infusion and acute four-compartment fasciotomy of the lower leg is the treatment. The risk of severe outcome of WLCS increases with duration of the primary operation. A broad support and change of legs' position during surgery are suggested preventative initiatives.

Doctor's delay in diagnosis of slipped capital femoral epiphysis.

INTRODUCTION: Slipped capital femoral epiphysis (SCFE) is one of the most common hip disorders in the adolescent child. The primary treatment is acute epiphysiodesis. Diffuse symptomology seems to delay diagnosis and delayed treatment entails a risk of complications. Via the independent Danish Patient Insurance Association (DPIA), Danish patients have been able to file a claim when an unexpected side effect or injury has resulted from their medical treatment. The DPIA is based on a no-blame, no-fault case evaluation, which is free of charge and without any legal action. We wanted to examine the causes of complaints through closed claim analysis. MATERIAL AND METHODS: In the DPIA, all medical statements and internal DPIA notes are stored and available for detailed scrutiny. Cases from 1996 to 2011 were investigated for treatment failures. RESULTS: A total of 40 cases were included. The mean age of the children was 12.4 years. A doctor's delay (DD) of the diagnosis was found in 27 case files, with an average 181-day delay. The education and specialisation of the doctors responsible was diverse. Often orthopaedic surgeons would make the correct diagnosis. Complications to surgery were found in 16 cases. In all, 22 of the 40 cases were economially compensated, 16 cases were categorised as "severe disability" by the DPIA. CONCLUSION: This study used closed claim analysis to determine that DD might result in a deteriorated treatment result in children with SCFE. Hopefully, awareness of the disease may lead to an earlier correct diagnosis and hence improve the outcome for the child. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Psychiatric claims to the Danish Patient Insurance Association have low recognition percentages.

INTRODUCTION: Since 1992 the Danish Patient Insurance Association (DPIA) has been receiving claims from patients who had suffered an injury during examination or treatment in Danish healthcare. We have presently collected more than 85,000 patient cases in our database, which we make accessible to research that can promote patient safety. We now want to draw attention to conditions that mainly apply to patients with mental disorders. MATERIAL AND METHODS: By searching the DPIA database over the past 15 years, we identified 1,278 patients with mental disorders. These patients were studied with respect to whether they had been treated within the psychiatric specialty or in a somatic specialty. During the study period, there was a change of opinion in the legal system after the Supreme Court ruled that surveillance of a psychiatric patient during admission, e.g. as anti-suicide precaution, should also be considered part of the treatment. RESULTS: Of the registered claims, 742 had received specialised psychiatric treatment for their mental disorders, and 536 had been treated in one of the somatic specialties. Of the 1,278 patients, 16% had their claims accepted. A marked difference was found in the acceptance rate of claims between these two groups: in psychiatry, 13% of the claims were accepted, whereas in the somatic specialties, the acceptance rate was 21%. Both of these numbers are well below the usual DPIA acceptance rate, which is 36% (p = 0.001). During the study period, there was a change in the Danish legal system after the Danish Supreme Court ruled that surveillance of a psychiatric patient during admission, e.g. as an anti-suicide precaution, should be considered part of the treatment. CONCLUSION: The low acceptance rate for claims made by patients with mental disorders concerning treatment or examination may, in part, be due to the lodging of unqualified claims, but other causes may also have contributed to this. Psychiatric patients who are treated for somatic disease should receive special attention to avoid treatment-related injuries. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Poor agreement between data from the National Patient Registry and the Danish Patient Insurance Association.

INTRODUCTION: Septic arthritis after knee arthroscopy requires in-patient treatment and should thus be reported to the National Patient Registry (NPR). It also meets the requirements for financial compensation if claimed to the Danish Patient Insurance Association (DPIA). The aim of this study was to assess data from the two independent data sources, the NPR and DPIA, with a view to comparing the registration of septic arthritis after knee arthroscopy. MATERIAL AND METHODS: This was a retrospective study assessing two three-year periods. From the NPR, we initially received all contacts coded as arthroscopic knee surgery. A second NPR query was made for patients found in the first query who had had a hospital contact within 30 days postoperatively with codes indicating septic arthritis (450 patients). Correspondingly, the DPIA files of patients claiming an infection following knee arthroscopy were searched to identify those (157 patients) with post-arthroscopic septic arthritis. RESULTS: We found poor agreement between the 450 patients in the second NPR data extraction and the 157 verified patients from the DPIA. Only 105 patients from DPIA were found in the NPR, while 52 patients in the DPIA were not returned as part of the second NPR data extraction. CONCLUSION: Coding of infections after arthroscopy in the NPR is inconsistent and incomplete. An underreporting of septic arthritis to the DPIA might exist.

Analysis of deaths among children in the period 1996-2008 from closed claims registered by the Danish Patient Insurance Association.

AIM: We investigated the death circumstances among children in the Danish healthcare system by analysing closed claims. METHODS: This retrospective study investigated closed claims with regard to medically related deaths registered by the Danish Patient Insurance Association. RESULTS: From 1996 to 2008, 45 953 claims were made to the Danish Patient Insurance Association (DPIA) covering all medical specialties. Among these claims, a total of 3531 submitted claims were for children younger than 18 years old, and 74 of these children were registered as having died. Forty-one of the 74 deaths were caused by peripartum asphyxia or other birth-related reasons, and 33 children died of causes not related to their birth. Twenty-three of the 33 children died as a result of substandard treatment. This was the ruling of the DPIA or the courts of law on the claim. In these cases, the DPIA, the appeal board or the courts of law settled that an experienced specialist would have acted differently such that the injury could have been avoided. CONCLUSION: Twenty-three of the 33 deaths after the perinatal period could potentially have been avoided if experienced specialists had handled the cases.

Analysis of 136 ureteral injuries in gynecological and obstetrical surgery from completed insurance claims.

OBJECTIVE: Iatrogenic ureteral injury during pelvic surgical procedures is a well-known complication and important cause of morbidity. The authors investigated the circumstances surrounding registered ureteral injuries in order to identify potential opportunities to prevent such injuries. DESIGN: Evaluation of claims concerning ureteral injuries reported to the Danish Patient Insurance Association. SETTING: Danish Patient Insurance Association. SAMPLE: All registered claims for ureteral injuries from 1996 to 2006. METHODS: Retrospective study of medical records and data from Danish Patient Insurance Association. MAIN OUTCOME MEASURES: Preventable ureteral injuries. RESULTS: From 1996 to 2006, 136 submitted claims concerning ureteral injuries were registered. Among these, 73 claims were approved (54%), and compensation paid. In 44 of these, the injury was caused by negligence. Failure to dissect the ureter despite indications for this procedure was the most common type of negligence. Laparotomy procedures were associated with 107 injuries (79%) and 29 injuries (21%) were caused during laparoscopic procedures. Thirty-four patients suffered from chronic renal dysfunction on the affected side. Only 17 of the ureteral injuries were discovered during the procedure. CONCLUSIONS: Forty-four ureteral injuries could potentially have been avoided using established surgical practices, most importantly by exposing the ureter via dissection when indicated. Most of the ureteral injuries were discovered postoperatively.

[Hypoxic brain injuries notified to the Danish Patient Insurance Association during 1992-2004. Secondary publication]. / Asfyksiskader anmeldt til Patientforsikringen i perioden 1992-2004--sekundaerpublikation.

We investigated the files of the Danish Patient Insurance Association for newborns suffering from hypoxic brain injuries. From 1992 to 2004, a total of 127 approved claims concerning peripartum hypoxic injury were registered. Thirty-eight newborns died and the majority of the 89 surviving children suffered major handicaps, primarily cerebral palsy. In 69 of the cases, misinterpretation of or late action in response to an abnormal cardiotocography caused the hypoxic brain injuries. All injuries could potentially have been avoided using established obstetric practice.

[Mediastinitis following cardiac surgery. Patient insurance reports]. / Mediastinitis efter hjertekirurgi. Et patientforsikringsmateriale.

INTRODUCTION: Mediastinitis in cardiac surgery is a well-known complication associated with high morbidity, invalidity, and mortality. Since the establishment by law of patients insurance in Denmark 1992, it has been possible to get compensation in some instances. MATERIALS AND METHODS: During a period of 8 years (1996-2003) 30 cases of mediastinitis were reported to the Danish Patient Insurance Association (DPIA). The initial cardiac operations consisted of 28 coronary artery bypass graft operations (CABG), 1 CABG associated with substitution of the aortic valve, and 1 CABG with cryoablation because of atrial fibrillation. The median preoperative mortality risk (EuroSCORE) was 2 (0-6+). The treatment of mediastinitis consisted of open revision or closed rinsing-system and of vacuum assisted closure in the later part of the period. RESULTS: Eighty percent of the patients had a transposition of thoracic muscle undertaken as a compensation for the lack of sternum. The median number of universal anaesthesias was 23 (3-32). The median admission time was 73 days (21-180), hospital mortality was 6.7%. A patient may receive compensation for an injury sustained during treatment if: 1) the best specialist would have acted differently, 2) the injury was caused by defect or malfunction of equipment, 3) the injury could have been prevented by using a different similar method of treatment, or 4) the patient had suffered more than is acceptable given the severity of the disease. Seventeen claims were approved (57%), the remainders were rejected. The criteria for acceptance according to the law of patient insurance are presented. In the actual period 511 cases of deep sternal infection after cardiac surgery were reported to the Danish Patient Registry. CONCLUSION: The majority of mediastinitis cases were not reported to the DPIA. The parties involved (patients, patient advisors, general practitioners, and hospital departments) are asked to concentrate on the need of reporting these cases to the DPIA.

[Pulmonary embolism with lethal outcome and claims to the Danish Patient Insurance Association]. / Dødelig lungeemboli og anmeldelse til Patientforsikringen.

INTRODUCTION: Venous thromboembolism can be prevented or treated by a variety of methods. Thrombosis may be prevented with drugs or by mechanical means in the exposed groups, and fully-developed thrombosis or embolism may be treated by thrombolysis or thrombectomy/embolectomy. MATERIALS AND METHODS: Pulmonary embolism (PE) with lethal outcome was the cause of five claims to the Danish Patient Insurance Association (DPIA) over five years (1996-2000). According to the registry of The National Board of Health, there were 1313 cases of death in which PE was the primary cause during this period. RESULTS: By reviewing the admission diagnoses and the operations, it was possible to select 923 patients who would have had little chance for compensation under the Patient Insurance Law. It is not possible to ascertain the chances of the remaining 390 patients of receiving compensation, but it is obvious that the frequency of reporting is far below the number of claims that could be accepted. CONCLUSION: Mortal PE is under-reported in claims to the DPIA. The reason for the lack of reporting is probably a lack of knowledge about the DPIA.

Analysis of 127 peripartum hypoxic brain injuries from closed claims registered by the Danish Patient Insurance Association.

BACKGROUND: One of the most feared complications in medicine is hypoxic brain damage to a newborn. The authors investigated the circumstances of registered peripartum hypoxic brain injuries in order to identify potential opportunities to improve patient safety and prevent injuries. METHODS: The authors retrospectively investigated peripartum hypoxic brain injuries registered by the Danish Patient Insurance Association. RESULTS: From 1992 to 2004, 127 approved claims concerning peripartum hypoxic brain injuries were registered and subsequently analysed. Thirty-eight newborns died, and a majority of the 89 surviving children suffered from major handicaps, primarily cerebral palsy. In 69 of the cases, misinterpretation of or late action on an abnormal cardiotocography (CTG) were the reasons for the majority of the hypoxic brain injuries. CONCLUSIONS: All injuries could potentially have been avoided using established obstetric practice. CTGs are often misinterpreted. In the authors' opinion, education and training in CTG interpretation is essential. The use of ST-analysis of the fetus ECG (STAN) could probably reduce the number of these injuries.

[Closed claims analysis of deaths related to anesthesia in the period 1996-2004 registered by the Danish Patient Insurance Association]. / Anaestesirelaterede dødsfald anmeldt til Patientforsikringen i perioden 1996-2004--sekundaerpublikation.

We investigated the Danish Patient Insurance Association's files on patients registered as dead after a complication to anaesthesia. In 24 cases the patient's death was considered to result from the anesthetic procedure: six deaths were related to airway or ventilation management, four to central venous catheter placement, four as a result of medication errors, four from infusion pump problems and four after complications from regional blockades. Severe hemorrhage caused one death, and in one case the cause was uncertain. Several of the 24 deaths could potentially have been avoided.

Analysis of deaths related to anesthesia in the period 1996-2004 from closed claims registered by the Danish Patient Insurance Association.

BACKGROUND: Anesthesia is associated with complications, and some of them may be fatal. The authors investigated the circumstances under which deaths were associated with anesthesia. In Denmark, the specialty anesthesiology encompasses emergency medicine, chronic and acute pain medicine, anesthetic procedures, perioperative care medicine, and intensive care medicine. METHODS: The authors retrospectively investigated anesthesia related deaths registered by the Danish Patient Insurance Association. RESULTS: From 1996 to 2004, 27,971 claims were made by the Danish Patient Insurance Association covering all medical specialties, of which 1,256 files (4.5%) were related to anesthesia. In 24 cases, the patient's death was considered to result from the anesthetic procedure: 4 deaths were related to airway management, 2 to ventilation management, 4 to central venous catheter placement, 4 as a result of medication errors, 4 from infusion pump problems, and 4 after complications from regional blockades. Severe hemorrhage caused 1 death, and in 1 case the cause was uncertain. CONCLUSIONS: Several of the 24 deaths could potentially have been avoided by more extended use of airway algorithm, thorough preoperative evaluation, training, education, and use of protocols for diagnosis and treatment.

[Patient injuries in response to anaesthetic procedures: cases evaluated by the Danish Patient Insurance Association--secondary publication]. / Anaestesiskader anmeldt til Patientforsikringen i perioden 1996-2002--sekundaerpublikation.

We investigated the Danish Patient Insurance Association files of patients, who were given financial compensation, because of an injury caused by an anaesthetic procedure. In the six-year-period 1996-2002, 374 patients were compensated in total 8.0 million euros for an injury caused by an anaesthetic procedure. Some anaesthetic complications may result in severe disability, whereby the financial compensation to the suffering patients is high. We estimate that approximately 0.2 per 1,000 of all patients receiving anaesthesia may develop complications that entitle them to financial compensation.