Summary
Background
In Europe, the increase in numbers of patients making legal claims might be due to better knowledge of their rights. In France, a law passed in 2002 provided new opportunities for claims.
Aim
To assess patient claims related to care in a French cardiology department.
Methods
From 2003 to 2007, claims brought before the courts and actions of conciliation within the scope of the hospital were collected by year. Cardiology department claims were individualized and compared with those for other departments. Characteristics of patients at the time of the care that prompted the claim, percentage of deaths, reasons for claims and claim results were collected.
Results
During the 4-year study period, 14% ( n = 45,272) of hospital admissions concerned cardiology, uniformly distributed across the years. In the same period, 845 procedures were recorded, 81 of which related to cardiology. The complaints index was 2.59/1000 patients for the general population and 1.79/1000 for cardiology. The 81 cardiology complaints (52 mediations; 29 litigations) concerned patients aged 62 ± 13 years (68% men). The number of cardiology claims remained stable from 2003 to 2007. Compared with claims concerning other departments, the nature of the plaintiff (more often heirs or husband/wife) and the reason for the claim (less frequently medical care problems; more often death and nosocomial infections) were statistically different.
Conclusion
Claims related to cardiology care were low and relatively stable over the past 4 years. Nosocomial infections prompted a high proportion of claims and should lead physicians to be vigilant. Cardiology remains relatively protected from litigation. A national registry of hospital claims might be valuable.
Résumé
Contexte
En Europe, une meilleure connaissance des droits du patient pourrait expliquer le développement d’opportunités de dépôt de plainte à la suite d’une hospitalisation. En France, une nouvelle loi votée en 2002 offre de nouvelles possibilités de réclamation. Il était donc intéressant d’évaluer les plaintes des patients en rapport avec les soins dans un pôle universitaire français de cardiologie.
Méthodes
De 2003 à 2007, les plaintes déposées devant les tribunaux et les actions de conciliation à l’hôpital étaient recueillies par année. Les plaintes concernant le pôle de cardiologie étaient individualisées et comparées à celles des autres pôles de l’hôpital. Les principales caractéristiques des patients au moment de la prise en charge à l’origine de la plainte, le pourcentage de décès, les différentes sortes de motivation, et les résultats des plaintes en termes de condamnation étaient colligés.
Résultats
Pendant la période d’étude de quatre ans, 14 % ( n = 45 272) des admissions hospitalières globales concernaient le pôle de cardiologie, distribuées uniformément selon les différentes années. Pendant la même période, 845 procédures étaient enregistrées parmi lesquelles 81 pour le pôle de cardiologie. Le taux indexé de réclamations était de 2,59 ‰ patients pour la population générale, et de 1,79 ‰ patients pour la population de cardiologie. Les 81 réclamations (52 procédures de médiation et 29 actions en justice) concernaient des patients d’âge moyen 62 ± 13 ans (68 % d’hommes). Le nombre de plaintes restait stable en cardiologie de 2003 à 2007. Comparés aux plaintes dans les autres pôles de l’hôpital, la qualité du plaignant (plus souvent les héritiers ou le conjoint) et le type de motivation (moins fréquemment les problèmes de soins médicaux, et plus souvent le décès et les infections nosocomiales) apparaissaient significativement différentes.
Conclusion
Les plaintes en lien avec les soins en cardiologie sont peu nombreuses et relativement stables en nombre au cours des quatre dernières années. Les maladies infectieuses nosocomiales en représentent une grande partie et devraient conduire les médecins à être extrêmement vigilants. La cardiologie demeure un domaine relativement protégé des actions en justice. Un registre national des plaintes hospitalières pourrait avoir un grand intérêt.
Background
In the USA, medical malpractice litigation is commonplace . An official report on reform of the medical litigation system relates that the excesses of the litigation system are an important contributor to ‘defensive medicine’ . In a large number of Council of Europe member states, the number of complaints and cases related to medical liability is increasing . In France, at the end of the 1990s, there was a marked increase in insurance payments. Specific specialists could no longer obtain insurance despite never having had a single malpractice judgment or even having faced a claim. At the same time, the French parliament considered no-fault injury compensation. A new law passed in 2002 reformed the health system. It gave new rights to the patients, fixed improvement of the quality of the health system as an objective and reformed the mode of medical responsibility. Hence, it gave patients new and easier opportunities for making claims. Thus, the aim of our study was to assess patient claims related to care in a university cardiology department during the past 4 years. We chose to focus on cardiology because of its invasive nature, the seriousness of the pathology, and the increased risk of problems and claims. This evaluation was done to find out the proportion of cases decided in favour of the patients or the hospital, and the nature of the accusation of malpractice that led the decision.
Methods
Description of the different types of claims in France
Legally, users of French healthcare institutions (patients and their families) must have the opportunity to express complaints directly to the administrative department of the hospital in question. Patients (or heirs) making a complaint against a hospital can choose between several options, according to the intensity, gravity or animosity that they feel. In general, the patient’s first step is to address a letter expressing dissatisfaction to the director of the hospital. If the matter is simple dissatisfaction, the patient is directed towards the medical mediator. If the patient wants to file a lawsuit, their letter (called an application for an ex-gratia settlement) is addressed to the legal department of the hospital.
Patients have three appeal procedure possibilities for payment of their litigation against the hospital: a traditional contentious procedure (court lawsuit), a mutual agreement and an amicable litigation settlement procedure established in the new 2002 French law on patients’ rights. This law founded a new commission, named the CRCI. This commission can be used by any person who is thought to be a victim of damage due to a medical accident, an iatrogenic accident or a nosocomial infection. When the damage to the patient reaches the threshold of gravity identified in the 2002 law, the CRCI is qualified to act and gives an opinion on the applicable mode of compensation in the 6 months after its involvement. The patient should undergo expert examination. If medical responsibility is confirmed, the opinion of the CRCI is sent to the hospital and to its insurer. An offer of compensation should be made during the next 4 months. If the victim accepts the offer, compensation must be paid within 1 month. If the victim refuses the offer, the court of jurisdiction should be used to assess the damage. If there is no medical fault, but only an iatrogenic accident or a nosocomial infection, the national office (ONIAM) must propose compensation to the patient.
Mediation: intervention of a medical mediator
The medical mediator is approached by the director of the hospital or directly by the patient (or heirs) to act as an intermediary, who provides the patient or their family with information, with the aim of resolving conflict between healthcare professionals and patients. The medical mediator is generally a retired doctor from the hospital in question, who has an excellent reputation that is recognized by both the medical community and patients. This function is generally not remunerated.
Legal representatives other than the patient
Complaints may be made by people other than the patient. If the patient is a minor, their legal representatives (parents or guardian) make the complaint. If the patient is still hospitalized, or if their health prevents them from making a complaint, their family (spouse, children, etc.) generally do so. Finally, if the patient is deceased, the heirs act on their behalf.
Data collection
From 2003 to 2007, all new complaints (claims brought to the courts and actions of mediation) within the scope of Nancy University Hospital were collected by year. Procedures started before 2003 and still pending were excluded. Complaints concerning the cardiology department (medicine, surgery and rehabilitation units, for both adults and children) were individualized. Reasons for claims and results of claims in terms of sentence were also collected. For each complaint, we recorded the surname, first name, date of birth and sex of the patient, the date of hospital discharge, the date of death (if relevant), the date of the complaint, and the authority used (medical mediator, legal department of the hospital for amicable agreement, CRCI, Administrative Court, Civil Court or Penal Court). We also recorded the department concerned with the complaint, the nature of the plaintiff (if not the patient), the reason for the recourse and the status of the procedure at the time of the study (in progress, hospital sentenced, patient claim rejected, renunciation of proceedings, therapeutic hazard or nosocomial infection).
Owing to changes in hospital organization, it was impossible to collect data from the legal department concerning amicable agreement for the year 2003. Before 2002, no systematic follow-up was performed for any type of claim.
Statistical analysis
Quantitative variables are expressed as means ± standard deviations and qualitative variables as numbers and percentages. Characteristics between groups were compared using Pearson’s Chi 2 test for categorical variables, and the t test or analysis of variance for continuous variables. Two analyses were performed: an analysis per patient, considering first registered procedure for a given patient, and an analysis per procedure. A P value < 0.05 was considered to be significant.
Results
General population
Patients and procedures
Over the study period, 326,661 patients were admitted to the hospital; 9610 (2.94%) died during hospitalization. A total of 845 procedures were recorded, concerning 771 patients ( Table 1 ). These patients were men in 54% of cases and had a mean age of 51 ± 23 years. Of the 845 procedures, 533 (63%) were addressed to the medical mediator and 312 (37%) were other types of complaints: 112 (13%) were addressed to the CRCI, 100 (12%) to the Administrative Court, 91 (11%) to the legal department of the hospital for amicable agreement, eight (1%) to the Civil Court, and one (0.1%) to the Penal Court. Globally, over the studied period, the complaints index was 2.59 per 1000 patients.
| Total complaints ( n = 845) | Mediation ( n = 533) | Litigation ( n = 312) | P | |
|---|---|---|---|---|
| Type of complaint | – | |||
| Mediation | 533 (63) | 533 (100) | – | |
| Amicable agreement | 91 (11) | – | 91 (29) | |
| CRCI | 112 (13) | – | 112 (36) | |
| Administrative Court | 100 (12) | – | 100 (32) | |
| Civil Court | 8 (1) | – | 8 (3) | |
| Penal Court | 1 (0.1) | – | 1 (0.3) | |
| Year when complaint was made | 0.001 | |||
| 2003 a | 135 (16) | 96 (18) | 39 (13) | |
| 2004 | 176 (21) | 117 (22) | 59 (19) | |
| 2005 | 217 (26) | 142 (27) | 75 (24) | |
| 2006 | 170 (20) | 106 (20) | 64 (21) | |
| 2007 | 147 (17) | 72 (14) | 75 (24) | |
| Mean age (years) | 51 ± 23 | 52 ± 24 | 47 ± 19 | 0.01 |
| Men | 459 (54) | 273 (51) | 186 (60) | 0.02 |
| Plaintiff | < 0.0001 | |||
| Patient | 471 (56) | 225 (42) | 246 (79) | |
| Heirs | 65 (8) | 50 (3) | 15 (16) | |
| Patient’s parents | 94 (11) | 79 (15) | 15 (5) | |
| Patient’s children | 108 (13) | 108 (20) | – | |
| Husband/wife | 77 (9) | 77 (14) | – | |
| Patient’s family | 11 (1) | 11 (2) | – | |
| Patient’s insurance company | 11 (1) | 11 (2) | – | |
| Patient’s general practitioner | 7 (1) | 7 (1) | – | |
| Reason | < 0.0001 | |||
| Medical care problems | 421 (50) | 335 (63) | 86 (28) | |
| Death of the patient | 98 (12) | 53 (10) | 45 (14) | |
| Nosocomial infections | 96 (11) | 31 (6) | 65 (21) | |
| Management of care | 74 (9) | 74 (14) | 0 | |
| After-effects of surgery | 116 (14) | 0 | 116 (37) | |
| Lack of information | 33 (4) | 33 (6) | 0 | |
| Problem with paramedical staff | 7 (1) | 7 (1) | 0 | |
| Time period for court referral (days) | 350 ± 866 | 98 ± 504 | 963 ± 1195 | < 0.0001 |
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