Medico-legal claims in colorectal surgery: Analysis of 231 files.

PURPOSE OF THE STUDY: The patient undergoing surgery is at risk of complications, some of which can be serious; these can expose the surgeon or institution to claims for compensation of damages. The aim of this study is to analyze the surgical management of these situations in order to draw lessons, to improve the management of patients, and to prevent both complications and resulting claims. PATIENTS AND METHODS: Two visceral surgeons analyzed two hundred and thirty-one claims files. The patient's characteristics and data, the intervention, the source event of the claim, re-interventions, transfers, deaths and their causes were identified. Any error, whether it was identified by the expert or by the arbitration panel or court and vice versa was analyzed, including any amicable out-of-court agreement proposed by the insurance, even, if in certain cases, no real fault had been found. RESULTS: The mean age of the colon surgery patients was 62 years. The pathologies for which surgery was performed fell into three equal parts: colon cancer, sigmoid diverticulitis, and other pathologies. The event leading to the claim occurred during hospitalization in 69.2% of cases. The most common events prompting claims were anastomotic leak (34.1%) and injury to neighboring organs (16.4%). In 36.7% of cases, patients required transfer to another facility and 31.1% died. At least one fault or error was found in 46.8% of cases. Anastomotic leak has always been considered an inherent risk of colonic surgery. The main fault alleged was delay in management in nearly two out of three cases, including delays in communication, in physical and laboratory examination, medical treatment, re-operation, and transfer. CONCLUSION: Specific information was provided to the patient before surgery and an effective checklist to prevent complaints and complications. In the post-operative period, an active approach to management initiated without delay by the entire team when faced with any unexpected event favored a quick recovery and could avoid the complaints; exams, sometimes lacking, remain complementary as their names indicate.

[Valid liability law in surgery. Principles of legal requirements and clinical benchmarks exemplified by visceral surgery]. / Über das geltende Haftungsrecht in der Chirurgie. Grundsätzliche juristische Vorgaben und klinische Bezugspunkte am Beispiel der Viszeralchirurgie.

The spectacular increase in liability processes in the field of surgery and in particular in visceral surgery, necessitates an objectification of the conflict between surgical medical professionals and medico-legal institutions, firms of solicitors and courts. Out of court settlements assisted by expert opinion commissions of the Medical Council can avoid many legal conflicts. For improvement of the legal standpoint of a defendant medical professional an unambiguous, extensive and detailed documentation of medical examination findings, the indications for the planned operative intervention, extensive and detailed documentation on disclosure and informed consent of the patient for the planned operative intervention, an extensive, detailed careful and responsibly guided report of the operation as well as a systematic, orderly well-planned postoperative complication management are necessary to counter the accusation of an organizational failure of medical professionals and the accused hospital. The mutual building of confidence between surgical medical professionals and legal institutions is safeguarded by a comprehensive documentation and an unambiguous description and formulation of the medical discharge report on termination of inpatient treatment.

Quality control in gastrointestinal surgery.

We analyzed the Mexican legal framework, identifying the vectors that characterize quality and control in gastrointestinal surgery. Quality is contemplated in the health protection rights determined according to the Mexican Constitution, established in the general health law and included as a specific goal in the actual National Development Plan and Health Sector Plan. Quality control implies planning, verification and application of corrective measures. Mexico has implemented several quality strategies such as certification of hospitals and regulatory agreements by the General Salubrity Council, creation of the National Health Quality Committee, generation of Clinical Practice Guidelines and the Certification of Medical Specialties, among others. Quality control in gastrointestinal surgery must begin at the time of medical education and continue during professional activities of surgeons, encouraging multidisciplinary teamwork, knowledge, abilities, attitudes, values and skills that promote homogeneous, safe and quality health services for the Mexican population.

[Structures and volume standards in colon and rectal surgery]. / Qualitätsstrukturen und Mindestmengen in der Kolon- und Rektumchirurgie.

Applying the principle "practice makes perfect" to interventional medicine would mean that surgeons and departments with high treatment volumes for special procedures should have better results than low-volume institutions. In the last three decades several studies were published dealing with the association of therapy volume and treatment quality, e.g. in oncologic and vascular surgery as well as interventional cardiology. Concerning colorectal cancer it has been shown that an individual surgeon's case load is important but by far not the only therapy-associated prognostic factor. For example interdisciplinarity and multimodality including adequate pathological classification are no less important. For continual improvement of clinical outcome, quality management and control will grow in importance. Thus, it is necessary to develop structures and to specify standards for colorectal surgery. Based on the data available it is not yet possible to define minimum volumes for colorectal surgery.

[Value of the informed consent in digestive surgery? Prospective study 259 cases]. / Le consentement éclairé: quelle est sa valeur en chirurgie digestive? Etude prospective sur 259 cas.

SITUATION: In 1997 the Supreme Court of Justice decreed that "the doctor is responsible for giving his patient certain information and is obliged to prove that the information has been given". French surgical societies recommend using a form of informed consent signed by the patient applicable to all practices. AIMS: To evaluate a step taken systematically since 1999 in our department. PATIENTS AND METHODS: A prospective study was put into place for 259 patients candidate for elective surgery. All patients signed and returned the "informed consent" before surgery. The day of leaving the hospital, they answered a post-operative questionnaire to evaluate what they remembered of the "informed consent form" and the quality of information. RESULTS: Ninety three per cent of them remembered it. Eight per cent signed it without reading it. Eighty two per cent of the patients think that this document is useful for their medical records. Among the patients who did not read the informed consent form: 38% wished it gave more information, whereas only 16% of those who had read it, considered the given information inadequate. This difference is statistically (p=0.03) significant. CONCLUSION: The informed consent form gives a lot of information to the patients, but the surgeon is still obliged to do likewise. Patients who did not read the consent were less satisfied with the given information than those who had read it. The positive reaction of the patients in favour of the form makes it evident that the existence of the form reassures them.

[Outpatient operations and inpatient care changes according to section sign 115 b SGB V]. / Ambulante Operationen und stationsersetzende Eingriffe nach section sign 115 b SGB V.

The German self-governing bodies have concluded an agreement about ambulant operations and procedures which replaces the inpatient health care situation. It came into force on January 1, 2004. The published catalogue contains specific treatment procedures which define more clearly some problems that occur between the provision of outpatient and inpatient services in the German health care system. Clinical physicians and practising specialists now have equal rights to provide and to charge for the ambulant services that are included in this agreement. These conditions will play a role in the daily routine of hospitals and will influence treatment patterns. A comprehensive knowledge of the basic principles is essential. In the present article, the compulsory agreement and some resulting consequences are elucidated with special relevance to gastroenterology.