1. Background
Today, one of the pressing concerns of the forensic pathology is medical malpractice (1), with lethal medical malpractice representing a subgroup across a broad spectrum. As it stands now, primary care is an area where the risk of malpractice remains comparatively under-researched; as such, heightened awareness about malpractice claims related to this can give a clear sense of direction to risk management endeavors and educational strategies (2). A key area for health care professionals to understand is patients’ perception and degree of satisfaction with the existing health care system. Patients’ perception of medical malpractices plays a crucial role in their satisfaction (3) which can consequently affect their trust to their clinicians and their compliance with medical recommendations (4, 5). On the other hand, any unpleasant experience of patients with their physicians can adversely affect the patient-clinician relationship and heighten the likelihood of defensive medicine (6). Furthermore, an increase in malpractice claims is positively correlated with patients’ perceptions of harm. Apart from the rather significant amount of time wasted on handling such claims, their emotional and psychological impacts on physicians that can greatly undermine their performance should also be seriously considered. As a case in point, there is mounting evidence suggesting that the more the number of complaints lodged against a certain medical specialty, the fewer the number of candidates inclined to pursue that specialty (7). A further consequence of this can be low risk adaption (7). However, patients’ perceptions of medical malpractices should not be taken at face value as they may not represent an accurate picture of the status quo (3). According to Sandars and Esmail, between five and 80 errors occur in every 100000 visits in adverse events related to ambulatory settings (8). For example, an annual death toll of 17500 as a result of medical adverse events is likely in Germany (9). In addition, a 2001 study by Kohn et al. has suggested that adverse preventable medial events have been responsible for the death of 98000 patients in the US annually (10). One major contributory factor seems to be misdiagnosed or undiagnosed pathologies (11, 12). For example, one study suggested that 37% of claims about medical malpractice did not involve any errors and 3% of them did not have any proof of medical injuries (13, 14) Another study also suggested that financial issues, patients’ misconception of nondisclosure by the clinician, poor relationship between patients and their clinicians and others’ recommendations for enlisting legal advice were the main factors heightening the likelihood of patients submitting a malpractice complaint (15). Although the role of each of these factors contributing to legal actions is far from clear, what is almost certain is that a good rapport between patients and clinicians, full disclosure, and a simple apology in case of medical mistakes can go a long way in obviating the need for taking a legal action. A retrospective analysis of 4450 autopsies suspicious for medical malpractice by Madea (9, 16) in Germany in 2009 found that surgery accounted for 28.5% of these malpractices, with internal medicine, general territorial practice, emergency medicine, anesthesiology, orthopedics, gynecology, and pediatrics following with 15.7%, 9.7%, 5.7%, 3.5%, 2.8%, 2%, and 2% respectively. In only 4.24% of cases a causal link was ascertained between the confirmed malpractice and the patients’ death and medical malpractice was excluded in 64.5% of the cases.
2. Objectives
Since there has been no research regarding medical malpractice examination in Military Hospitals, this research aimed at examining complaint cases on medical malpractices within different medical disciplines in Military hospitals claimed to medical council and forensics of Tehran.
3. Patients and Methods
The method for this research was interim and explanatory-analytic. We studied all the cases in Military Hospitals claimed to Tehran central commission from 2006 to 2011.The form for registration of particulates was developed after studying books, papers, and related researches. This form contained the reasons for complaint, court order, patients’ age and gender, physicians’ age and gender, type of hospital, medical professions and physicians’ specialties. To measure scientific credibility through content validity method, two specialists were involved. Data resources included cases established for complaints on healthcare staff as well as registered data in computer files of forensics commissions department of Tehran. Data from cases included outpatient or impatient cases, cases related to diagnosis of forensics centers, autopsy of dead cases, penal cases of courts, performed diagnoses and advice by the commissions department, and finally minutes of the commission to examine malpractices and healthcare staff. Computer files included personal information of patients and healthcare staff as well as the minutes provided by the commission. Since the complaints and computer files contained personal information of staff and patients, data collection was performed by confident and loyal people. Data was analyzed through SPSS version 16 software. Qualitative data was explained using mean, standard deviation, mean of standard error, and the highest and the lowest values.
4. Results
There were 59 proven complaint cases on medical malpractices related to Military Hospitals, claimed to forensics and medical council of Tehran during 2006-2011,from which only 41 cases had provided full information and were examined in this study and 4 (9.75%) cases were related to 2006, 5 (12.19%) to 2007, 6 (14.63%) reviews were related to 2008, 7 (17.07%) to 2009, 8 (19.51%) to 2010 and 11 (26.82%) to 2011; 36 cases (87.7%) were related to male physicians while females made up only 5 cases (12.2%); the mean age of physicians was 43.91 ± 8.28. The mean of medical activity was 24.15 years. The mean age of complaining patients was 36.61 ± 17.12; 21 (51.22%) were male and 20 (48.8%) were female; 30 (39%) patients were under diploma, 16 (39%) had high school diploma and 12 (29.3%) had B.A. or higher education. Within 41 proven malpractices, 15 (36.58%) were of indiscretion type, 12 (29.26%) imprudence, 10 (24.39%) lack of practical and scientific skills, and 4 (9.75%) fail to observe state regulations, which were committed by general physicians. In the case of locations of healthcare activities resulting to malpractices, 9 (22%) cases were related to outpatient clinics and 32 (78%) to inpatients. The complaints ended up with malpractice were examined based on medical specialties; the highest levels of malpractice were related to orthopedics (22%), general physicians (14.6%), general surgery (12.2%), and anesthesia (9.8%) (Table 1).
Table 1. Medical Malpractice Frequency Based on Medical Specialty
| Discipline | Malpractice Frequency |
|---|---|
| Orthopedics | 9 (22) |
| General physician | 6 (14.6) |
| General surgery | 5 (12.2) |
| Anesthesia | 4 (9.8) |
| Neurosurgery | 3 (7.3) |
| Obstetrics and gynecology | 3 (7.3) |
| Oculist | 2 (4.9) |
| Ear, nose ,throat | 2 (4.9) |
| Internal | 2 (4.9) |
| Plastic surgery | 2 (4.9) |
| Physical medicine | 2 (4.9) |
| Urology | 1 (2.4) |
5. Discussion
Today, medical affairs specialization and financial and social difficulties have led to destruction of the traditional relationship between physicians and patients. Although reasons like population growth, the ever-increasing number of physicians and insured people, and heightened consciousness about their own rights have led to an increase in the number of complaints against physicians, failure of physicians is one of the major reasons of those claims. International reports on complaints frequency in different countries suggest that the number of complaints is growing regardless of considerable scientific developments and modern technologies in diagnosis and healthcare. In this paper there was an ascending trend for complaints during 2006-2011, showing an upward trend for complaints and proven cases of medical malpractices. A research titled “examination of complaint cases on medical malpractices in orthopedics”, performed in general department of Tehran forensics during 1998-2003, showed that complaints on orthopedic specialty rose from 15 cases in 1377 to 39 in 1382, which was not linear but confirmed by other similar studies (17). Other researches also suggest a growing trend in the number of complaints. For one, Dettmeyer et al.’s evaluation of medical malpractice charges including both lethal and nonlethal cases in the German city of Bonn within a 13-year period (1989-2002) suggested that general surgery and gynecology were more involved than other branches in these legal actions (18). Reports released by the English NHS Litigation Authority also cited surgery and gynecology as the most involved branches. However, a case in Turkey is a little different. According to Juvin et al.’s study of lethal and non-lethal malpractice cases, malpractice claims were unfounded in 69.2% of cases, and in their case, at 16.8%, gynecology overtook general surgery at 10.7% in terms of high risk areas. These were followed by neurology/neurosurgery at 10.5%, and anesthesiology at 9.4% (12). Pakis et al. also studied only lethal cases, 70% of which were autopsies. In their study, in 31.8% of cases a real medical malpractice was ascertained, with gynecology and general surgery ranking the highest at 22% and 17.8%, respectively. They also found the mean age of death to be 26.8 (19). Therefore, along with a growing number of complaints, proven medical malpractices have also grown in number. This increasing number can somehow be explained by population growth, increasing number of recourses and advances in medical knowledge, but those mentioned causes may be studied more deeply in future and the medical society can benefit from the results to stop the increasing trend of complaints, or even decrease it (20). In a study by Tofighi et al. discussed in medical commission of forensics organization from 1374-1378, the most frequent complaints were related to general surgery, anesthesia, internal physician, gynecologist, brain and nerve surgeon, and general physician (21). In this research, 41 cases were examined, from which 22% were related to orthopedics, 14.6% to general physicians, 12.2% to general surgeons, 9.8% to anesthesia, and 7.3% to brain and nerve surgery, which are somewhat divergent with the results of prior researches. This may be derived from the fact that our research was only limited to hospitals as well as the high number of orthopedic surgeries and the high probability of their side effects and consequently the occurrence dissatisfaction and complaints of patients. However, in another study by Haghshenas et al. the highest recorded malpractice (22.28%) was related to orthopedic specialists and it was justified with the higher number of orthopedic surgeries in hospitals of Sari (22). In this study, regarding examination of medical malpractices, the highest proven cases were as follows: indiscretion (36.7%), imprudence (9.7%), lack of skill (9.7%), and failure to observe state regulations (7.7%). Our results were convergent with these ones such that the highest level of malpractice with 15 cases (36.58%) were related to indiscretion and 12 (29.26%) to imprudence. Here, we can conclude that the highest number of medical malpractices resulted from indiscretions and imprudence. On the other hand, the results of this study indicated that the lowest level of malpractices was associated with failure to observe the state regulations and lack of skills. These two stand for 1/6 of malpractice cases which may be improved up to an extent through holding training courses, cooperating with scientific research associations and other efforts. Cases resulting from imprudence and indiscretion can be minimized through efforts including better organization of healthcare systems, increasing insurance coverages, strict punishments and fines as well as medical ethics.
In conclusion, the results of this study indicated that medical malpractices and complaints were increasing compared to the past. On the other hand, most malpractice cases were reported to orthopedic specialists and general physicians and indiscretion and imprudence constituted the highest level in this regard. It is suggested that training courses can significantly prevent these malpractices. Complaints can be minimized by such measures as improving physicians’ skills related to patients during college courses and through holding training workshops and respecting ethical and legal regulations.
