[Analysis of brachial plexus injuries reported to MRM].

Upper-arm weakness (paresis) or paralysis in the newborn (Erb's palsy) usually indicates peripheral-nerve damage to the brachial plexus. Its location lateral to the lower cervical spine (C5-T1) renders it susceptible to injury by pressure or traction during pregnancy, labor or delivery. The Medical Risk Management (MRM), a "Madanes" group company, routinely receives adverse events reports from medical centers covered by its medical malpractice insurance. In the current study, the authors analyzed 536 reports of Erb's palsy in the newborn, with varying degrees of severity, which were reported to MRM during the years 1993-2004. A dedicated questionnaire with approximately 30 relevant variables was formed in order to analyze these reports. Reference values for pregnancies and deliveries in the general population were obtained from the Israeli Central Statistics Bureau, Information Department in the Ministry of Health, the Israeli Society of Maternal-Fetal Medicine, as well as relevant data in the medical literature. It was found that during the analyzed period of time, the reporting rate for Erb's palsy varied between 0.5-1.2 cases per 1,000 newborns. Compared with the general Israeli population, women in the study group were older, overweight, with higher parity and have diabetic traits. The authors noted a systematic error of underestimation of fetal weight, compared to the actual birth weight in our study group. Although, the majority of the Erb cases followed vaginal deliveries at term, 3% of the cases followed Cesarean sections, the majority of which were either elective or in early labor. A quarter of the Erb cases followed instrument delivery, while the rate of instrumental deliveries in the general population averaged only 5% throughout the study period. In half of the Erb cases, difficulty in extraction of the shoulder (shoulder dystocia) of the involved arm was found in the delivery medical record, but reference to shoulder or head extraction was noted in only half of the cases following vaginal deliveries. However, the rate of medical records with adequate reference to shoulder or head extraction increased from 44% in the beginning, to 74% at the end of the analyzed study period. The average birth weight of our study group was 3888+569 grams, which is significantly higher than the average birth weight in the general population. It was also noted that birth weights of Erb cases are of higher percentiles on the Israeli nomogram of gestational age adjusted birth weights. Thus, 53% of the newborns in our study group were above the 90th percentile and 31% above the 97th percentile of the general population nomogram. Various risk factors for brachial plexus injury were found in this large sample of Erb's palsy cases in Israel. However, the relative importance of each of these factors cannot be determined due to lack of an appropriate control group and valid reference data for the general population of pregnancies and deliveries during the analyzed study period. Nonetheless, the dedicated questionnaire, which was developed for this analysis, may assist in compiling real-time data to support the findings of this study.

Perianesthetic dental injuries: analysis of incident reports.

STUDY OBJECTIVE: To conduct a retrospective analysis of incident reports concerning dental injury, the most common cause for litigation against anesthesiologists, to determine specific risk factors that will help in formulating a risk reduction strategy for this clinical problem. DESIGN: Retrospective chart review of a large professional liability insurer. INTERVENTIONS: Of 40 hospitals that report to the MRM Co. as part of the professional liability insurance, during the years 1992-1999, 18 hospitals reported dental injury. A Maxillofacial surgeon (GN) and an anesthesiologist (ES), using a structured form, reviewed the reports. Evaluation of the cost of injury was determined from the patient's claims or from an evaluation of rehabilitation plan constructed by the maxillofacial surgery consultants to the company. MEASUREMENTS AND MAIN RESULTS: There were 203 incidents due to dental injury. The patients were most commonly in their 5(th) to 7(th) decade. Eighty six percent of the injured teeth were the upper incisors. Lower incisors were more likely to be injured during an urgent intubation, or due to airway manipulation other than intubation. (i.e., oral airway insertion) In only 38 (18.6%) cases was there a previous assessment of an expected difficult intubation. Dentition was judged to be pathological in 32% of the patients. CONCLUSIONS: In elective intubation, the teeth most likely to be injured are the upper incisors, in patients aged 50-70 years. In most cases dental injury is not associated with a pre-event prediction of difficult intubation.

[Informed consent--a simulation workshop for surgeons and gynaecologists].

BACKGROUND: Informed consent as part of the Israeli Patient's Rights Act (1996) is poorly known and only partly followed among physicians in Israel. PURPOSE: A one-day workshop on informed consent was designed with a dual purpose: a) to instruct on the legal requirements for obtaining consent to surgery for physicians in the surgical disciplines, and b) to practice effective and humane physician-patient relationships. METHODS: Sixty-one residents and senior staff took part in 6 sessions of a one-day workshop. Participants watched twice and performed twice videotaped simulated consent conversations with standardized patients. Six professional actors personified patients with common surgical problems and different characters and behaviours. Each participant was challenged with medical problems in her/his discipline. Following the first simulation, the participants attended a group discussion concerning legal requirements for informed consent, and expectations of patients and physicians in terms of communication skills and patient-physician relationships. Three types of feed-back were employed: a) non-professional personal feedback from the actors; b) personal feedback from a communication specialist using one of the videotaped encounters; and c) group discussions of each of the 6 types of simulations with examples from the encounters. RESULTS: Feedback from the participants was positive and showed interest and need of knowledge of the law as well as of communicative skills. CONCLUSIONS: There is a place, among residents and senior physicians, for experiential learning of how to effectively and humanely obtain informed consent.

Medicolegal aspects of altered sensation following implant placement in the mandible.

PURPOSE: Altered mandibular sensation following implant surgery may result in liability claims. Therefore the authors conducted a retrospective analysis of all liability claims related to persistent altered sensation following placement of mandibular implants reported to the Medical Consultants International (MCI) Company from 1992 to 1999. MATERIALS AND METHODS: Reports related to persistent altered mandibular sensation in 16 patients (12 women and 4 men) who underwent implant surgery in Israel were examined. The MCI files were retrospectively evaluated according to a structured form. The parameters studied included patient age and gender, implant location and length, imaging modality, and the time between actual damage and filing of a claim (ie, letter of demand or lawsuit). RESULTS: The time in months between actual damage and filing of claim ranged from 0 to 60 months (mean 21.5 months). No cases were found involving transient changes in sensation. The female/male ratio was 3:1. Implant length was equal to or longer than 13 mm in 6 of 7 implants placed in the molar region. In the premolar area, nerve injury was evident in 6 of 7 cases where implants shorter than 12 mm were used. CONCLUSIONS: Transient nerve injury rarely results in legal action. Maximum effort should be devoted to accurately determining the appropriate implant length in the mandible.

Risk management aspects of implant dentistry.

PURPOSE: To categorize and review complications related to implant dentistry that have resulted in legal actions. MATERIALS AND METHODS: The records of 61 patients (39 women and 22 men) were retrospectively evaluated according to a structured form. Ages ranged from 28 years to 78 years (mean 49 +/- 12 years). The time lag in months between actual damage and legal action ranged from 0 months to 60 months (mean 12.7 months). RESULTS: Implant type, length, width, and locations varied widely and had no impact on the liability report. Half of the lawsuits were filed as a result of actual body damage (loss of sensation, oroantral fistula, life-threatening bleeding); 35% of the lawsuits were filed because of late complications; and 15% were related to immediate complications not leading to actual body damage. The dental consultants acknowledged liability in 41 of 61 cases. The clinician's errors that led to the reported complication were classified as preoperative in 39 of 41 cases. The doctor's attitude was considered positive in 40 cases and negative in 17 cases. DISCUSSION AND CONCLUSIONS: Clinicians should report as soon as possible to their insurance companies to get professional help. The main causes for lawsuits are actual body injury and major disappointment. Practitioners should dedicate a significant part of the entire treatment time to preoperative diagnosis and planning.