Counting the cost of negligence in neurosurgery: Lessons to be learned from 10 years of claims in the NHS

References

• Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty. N Engl J Med 2011;365: 629–36.
   PubMed Web of Science ®Google Scholar
• Todd NV. Medical negligence. An overview of legal theory and neurosurgical practice: duty of care. Br J Neurosurg 2013:1–5.
   Google Scholar
• Zhang Z-Y, Yao Y, Zhou L-F. Perspectives. World Neurosurg 2014;81:244–6.
   PubMedGoogle Scholar
• Emery E, Balossier A, Mertens P. Is the medicolegal issue avoidable in neurosurgery? A retrospective survey of a series of 115 medicolegal cases from public hospitals. World Neurosurg 2014;81:218–22.
   Google Scholar
• De Santis A. Neurosurgery in the law court. J Neurosurg Sci 2004;48:97–103.
   PubMedGoogle Scholar
• Rovit RL, Simon AS, Drew J, Murali R, Robb J. Neurosurgical experience with malpractice litigation: an analysis of closed claims against neurosurgeons in New York State, 1999 through2003. J Neurosurg 2007;106:1108–14.
   Google Scholar
• Fager CA. Malpractice issues in neurological surgery. Surg Neurol 2006;65:416–21.
   PubMed Web of Science ®Google Scholar
• Chi JHJ. Neurosurgery tops malpractice risk. Neurosurgery 2011;69:N18–N20.
   PubMedGoogle Scholar
• Dean M. UK concern over reuse of neurosurgical tools. Lancet 2002;360:1485.
   PubMedGoogle Scholar
• Samuels A. Did the neurosurgeon warn the patient of the risks? Br J Neurosurg 2003;17:117–20.
   PubMed Web of Science ®Google Scholar
• Todd NVN. Causes and outcomes of cauda equina syndrome in medico-legal practice: a single neurosurgical experience of 40 consecutive cases. Br J Neurosurg 2011;25:503–8.
   PubMed Web of Science ®Google Scholar
• Mitchell P, Nicholson CL, Jenkins A. Side errors in neurosurgery. Acta Neurochir 2006;148:1289–92.
   PubMed Web of Science ®Google Scholar
• McNeill A. Neurological negligence claims in the NHS from 1995 to 2005. Eur J Neurol 2007;14:399–402.
   PubMedGoogle Scholar
• Quraishi NA, Hammett TC, Todd DB, Bhutta MA, Kapoor V. Malpractice litigation and the spine: the NHS perspective on 235 successful claims in England. Eur Spine J 2012;21:196–9.
   Google Scholar
• McNeill A, Mathewson B. Negligence claims for treatment of neurological disease: cases from the Medical and Dental Defence Union of Scotland. Scott Med J 2006;51:24–5.
   PubMedGoogle Scholar
• Negligence claims for neurological diseases 2003-13. http://www.nhsla.com (accessed 01/11/2013).
   Google Scholar
• Hospital Episode Statistics. http://www.hscic.gov.uk/hes (accessed 02/03/2014).
   Google Scholar
• Khan IH, Jamil W, Lynn SM, Khan OH, Markland K, Giddins G. Analysis of NHSLA claims in orthopedic surgery. Orthopedics 2012;35:e726–31.
   PubMedGoogle Scholar
• Gulati A, Herd MK, Nimako M, Anand R, Brennan PA. Litigation in National Health Service oral and maxillofacial surgery: review of the last 15 years. Br J Oral Maxillofac Surg 2012;50:385–8.
   PubMed Web of Science ®Google Scholar
• Fenn P, Gray A, Rickman N, Towse A. Making amends for negligence. BMJ 2004;328:417–8.
   PubMedGoogle Scholar
• Somville F, van Sprundel M, Somville J. Analysis of surgical errors in malpractice claims in Belgium. Acta Chir Belg 2010;110: 11–8.
   PubMed Web of Science ®Google Scholar
• Svider PF, Sunaryo PL, Keeley BR, et al. Characterizing liability for cranial nerve injuries: a detailed analysis of 209 malpractice trials. Laryngoscope 2013;123:1156–62.
   PubMed Web of Science ®Google Scholar
• NHSLA Report and Accounts 2012-2013. http://www.nhsla.com (accessed 10/03/2014).
   Google Scholar
• Kane K. Policy Research Perspectives Medical Liability Claim Frequency: A 2007–2008 Snapshot of Physicians. 2010.
   Google Scholar
• Balch CM, Oreskovich MR, Dyrbye LN, et al. Personal consequences of malpractice lawsuits on american surgeons. J Am Coll Surg 2011;213:657–67.
   PubMed Web of Science ®Google Scholar
• Deshpande SP, Deshpande SS. Career satisfaction of surgical specialties. Ann Surg 2011;253:1011–6.
   PubMedGoogle Scholar
• Guest RS, Baser R, Li Y, et al. Cancer surgeons’ distress and well-being, II: modifiable factors and the potential for organizational interventions. Ann Surg Oncol 2011;18:1236–42.
   PubMedGoogle Scholar
• Eddleman CS, Aoun SG, Batjer HH. How to identify the edge of a cliff in the dark: burnout and neurosurgery. World Neurosurg 2013;80:e111–3.
   PubMedGoogle Scholar
• NHSLA Factsheet 3: Information on claims. http://www.nhsla.com (accessed 03/03/2014).
   Google Scholar
• Ali N, Little BC. Causes of cataract surgery malpractice claims in England 1995-2008. Br J Ophthalmol 2011;95:490–2.
   Google Scholar
• Cowie CJA, Pešić-Smith JD, Boukas A, Nelson RJ, Nelson RJ. Has the impact of the working time regulations changed neurosurgical trainees’ attitudes towards the European working time directive 5 years on? Br J Neurosurg 2013;27:580–5.
   PubMed Web of Science ®Google Scholar
• Tait MJ, Fellows GA, Pushpananthan S, et al. Current neurosurgical trainees’ perception of the European Working Time Directive and shift work. Br J Neurosurg 2009;22:28–31.
   Google Scholar
• Maxwell AJA, Crocker MM, Jones TLT, et al. Implementation of the European Working Time Directive in neurosurgery reduces continuity of care and training opportunities. Acta Neurochir (Wien). 2010;152:1207–10.
   PubMed Web of Science ®Google Scholar
• Breen KJ, Hogan AM, Mealy K. The detrimental impact of the implementation of the European working time directive (EWTD) on surgical senior house officer (SHO) operative experience. Ir J Med Sci 2013;182:383–7.
   PubMed Web of Science ®Google Scholar
• Marron CD, Byrnes CK, Kirk SJ. An EWTD-compliant shift rota decreases training opportunities. Bull R Coll Surg Engl 2005;87:246–8.
   Google Scholar
• Greenway D. Securing the future of excellent patient care. 2013 Dec pp. 1–57.
   Google Scholar
• NHS England: Never Events data. http://www.england.nhs.uk/ourwork/patientsafety/never-events/ne-data/ (accessed 21/03/2014).
   Google Scholar
• Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg 2006;141:353–8.
   PubMedGoogle Scholar
• Jhawar BS, Mitsis D, Duggal N. Wrong-sided and wrong- level neurosurgery: a national survey. J Neurosurg Spine 2007;7: 467–72.
   PubMed Web of Science ®Google Scholar
• Shinde S, Carter JA. Wrong site neurosurgery–still a problem. Anaesthesia 2009;64:1–2.
   PubMedGoogle Scholar
• Groff MW, Heller JE, Potts EA, et al. A survey-based study of wrong-level lumbar spine surgery: the scope of the problem and current practices in place to help avoid these errors. World Neurosurg 2013;79:585–92.
   PubMed Web of Science ®Google Scholar
• Vachhani JA, Klopfenstein JD. Incidence of neurosurgical wrong-site surgery before and after implementation of the universal protocol. Neurosurgery 2013;72:590–5.
   PubMedGoogle Scholar
• NPSA-Avoiding wrong side burr holes-craniotomy. http://www.nrls.npsa.nhs.uk/resources (accessed 01/04/2014).
   Google Scholar
• Alkhaffaf B, Decadt B. Litigation following groin hernia repair in England. Hernia 2010;14:181–6.
   PubMedGoogle Scholar
• A follow- up review of wrong site surgery. The Joint Commission on Accreditation of Health Care Organisations. http://www.jointcommission.org (accessed 20/03/2014).
   Google Scholar
• Hussain SA, Gullan RW, Chitnavis BP. Cauda equina syndrome: outcome and implications for management. Br J Neurosurg 2003;17:164–7.
   PubMed Web of Science ®Google Scholar
• Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur Spine J 2011;20:690–7.
   PubMed Web of Science ®Google Scholar
• Gleave JRW, Macfarlane R. Cauda equina syndrome: what is the relationship between timing of surgery and outcome? Br J Neurosurg 2002;16:325–8.
   PubMed Web of Science ®Google Scholar
• McCarthy MJH, Aylott CEW, Grevitt MP, Hegarty J. Cauda equina syndrome: factors affecting long-term functional and sphincteric outcome. Spine 2007;32:207–16.
   PubMed Web of Science ®Google Scholar
• Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9.
   PubMed Web of Science ®Google Scholar
• Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf 2013;23: 299–318.
   PubMedGoogle Scholar
• de Vries EN, Eikens-Jansen MP, Hamersma AM, et al. Prevention of surgical malpractice claims by use of a surgical safety checklist. Ann Surg 2011;253:624–8.
   PubMed Web of Science ®Google Scholar
• Semel ME. Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals. Health Aff 2010;29:1593–9.
   Google Scholar
• Robb WB, Falk GA, Larkin JO, Waldron R, Waldron RP. A 10-step intraoperative surgical checklist (ISC) for laparoscopic cholecystectomy-can it really reduce conversion rates to open cholecystectomy? J Gastrointest Surg 2012;16:1318–23.
   PubMedGoogle Scholar
• de Vries EN, Prins HA, Bennink MC, et al. Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients. BMJ Qual Saf 2012;21:503–8.
   PubMedGoogle Scholar
• Liu W, Neidert MC, Groen RJM, Woernle CM, Grundmann H. Third-generation cephalosporins as antibiotic prophylaxis in neurosurgery: what's the evidence? Clin Neurol Neurosurg 2014;116:13–9.
   PubMedGoogle Scholar
• Liu W, Ni M, Zhang Y, Groen RJM. Antibiotic prophylaxis in craniotomy: a review. Neurosurg Rev 2014:1–8.
   Google Scholar
• Fargen KM. Enhanced staff communication and reduced near-miss errors with a neurointerventional procedural checklist. J NeuroInterv Surg 2013;5:497–500.
   PubMedGoogle Scholar
• Lyons MK. Eight-year experience with a neurosurgical checklist. Am J Med Qual 2010;25:285–8.
   PubMedGoogle Scholar
• Zuckerman SL, Green CS, Carr KR, et al. Neurosurgical checklists: a review. Neurosurg Focus 2012;33:E2–E2.
   PubMedGoogle Scholar
• Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of Surgical Safety Checklists in Ontario, Canada. N Engl J Med 2014;370:1029–38.
   PubMed Web of Science ®Google Scholar
• Pickering SP, Robertson ER, Griffin D, et al. Compliance and use of the World Health Organization checklist in UK operating theatres. Br J Surg 2013;100:1664–70.
   PubMed Web of Science ®Google Scholar
• Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Reality check for checklists. Lancet 2009;374:444–5.
   PubMed Web of Science ®Google Scholar
• Liebman CB, Hyman CS. A mediation skills model to manage disclosure of errors and adverse events to patients. Health Aff 2004;23:22–32.
   Google Scholar
• Schenker Y, Fernandez A, Sudore R, Schillinger D. Interventions to improve patient comprehension in informed consent for medical and surgical procedures: a systematic review. Med Decis Making 2011;31:151–73.
   PubMed Web of Science ®Google Scholar
• Keulers BJ, Scheltinga M, Houterman S. Surgeons underestimate their patients’ desire for preoperative information. World J Surg 2008;32:964–70.
   PubMed Web of Science ®Google Scholar
• Francis R. Final report | Mid Staffordshire NHS Foundation Trust Public Inquiry. http://www.midstaffspublicinquiry.com/report (accessed 20/03/2014).
   Google Scholar
• Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med 1994;154:1365–70.
   PubMed Web of Science ®Google Scholar
• Academy of Medical Royal Colleges. Guidance for Taking Responsibility: Accountable Clinicians and Informed Patients. Http://www.aomrc.org.uk/images/dmdocuments/aomrc_papers_takingresponsibility_final.pdf (accessed 28/08/2014).
   Google Scholar
• Rittman T, Corns R, Kumar A, Bhangoo R, Ashkan K. Is referral to the neuro-oncology MDT safe? Br J Neurosurg 2012; 26:321–4.
   PubMed Web of Science ®Google Scholar
• Localio AR, Lawthers AG, Brennan TA, et al. Relation between malpractice claims and adverse events due to negligence. N Engl J Med 1991;325:245–51.
   PubMed Web of Science ®Google Scholar
• The Society of Cardiothoracic Surgeons National Adult Cardiac Surgery Database. www.scts.org/professionals/audit_outcomes/cardiac.aspx (accessed 28/08/2014).
   Google Scholar