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Yaron Niv1, Yael Gershtansky2, Ron S Kenett3, Yossi Tal2, Shlomo Birkenfeld41Department of Gastroenterology, Rabin Medical Center, Petach Tikva, Israel; 2Medical Risk Management, The Madanes Group, Tel Aviv, Israel; 3The KPA Group, University of Torino, Turin, Italy; 4Clalit Health Services, Tel Aviv, IsraelIntroduction: The number of malpractice claims against physicians and health institutes is increasing continuously in Israel as in the rest of the Western world, and has become a serious financial burden.Aim: In this study we analyzed the reports of gastroenterologists on endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) adverse events to the risk management authority between January 1, 2000 and December 31, 2006.Methods: All the reported adverse events associated with ERCP and EUS of health institutes and covered by Madanes Insurance Agency were summarized and analyzed. Clinical and epidemiological details about the patients, procedures, and adverse events were coded into an Excel worksheet, discussed, and evaluated.Results: Forty-two cases of ERCP and EUS adverse events were reported. There were nine cases of men (21.4%) and the average age was 69.3 ± 14.3 years. During this period, 10,647 procedures were performed by the institutes concerned and the number of adverse events was 20.2 to 67.8 per year for 10,000 procedures. Perforation occurred in one out of 367 procedures, bleeding in one out of 5323 procedures, teeth trauma in one out of 5323 procedures, and respiratory complications in one out of 10,647 procedures.Conclusion: This is the first study in Israel about physicians' reports of ERCP and EUS adverse events. Physicians reported only about severe adverse events with high rate of mortality and morbidity.Keywords: ERCP, EUS, defensive medicine, perforation, bleeding, sedation, risk management, patient safety

Background: Removal of retained placental tissue postpartum and retained products of conception (RPOC) abortion is done by uterine curettage or hysteroscopy. Trauma to the endometrium from surgical procedures, primarily curettage, can cause intrauterine adhesions (Asherman's syndrome) and subsequent infertility. The incidence of malpractice claims relating to intrauterine adhesions is rising, justifying reevaluation of the optimal way of handling these complications., Objectives: To review malpractice claims regarding intrauterine adhesions, and to explore the clinical approach that might reduce those claims or improve their medical and legal outcomes., Methods: We examined 42 Asherman's syndrome claims handled by MCI, the largest professional liability insurer in Israel. The clinical chart of each case was reviewed and analyzed by the event preceding the adhesion formations, timing and mode of diagnosis, and outcome. We also assessed whether the adverse outcome was caused by substandard care and it it could have been avoided by different clinical practice. The legal outcome was also evaluated., Results: Forty-seven percent of the cases occurred following vaginal delivery, 19% followed cesarean section, 28% were RPOC following a first-trimester pregnancy termination, and 2% followed a second-trimester pregnancy termination., Conclusions: It is apparent that due to the lack of an accepted management protocol for cases of RPOC, it is difficult to legally defend those cases when the complication of Asherman syndrome develops.

Introduction: The number of negligence claims against physicians and health institutes is increasing and has become a serious financial problem. Reporting adverse events became a mandatory behavior for quality assurance purposes and for preparing potential claims., Aim: To evaluate endoscopists' reports on adverse events in esophagogastroduodenoscopy (EGD)., Methods: We analyzed all the reports of gastroenterologists on EGD adverse events to the risk management authority, between January 1, 2000, and December 31, 2006. Clinical and epidemiological details about the patients, procedures, and adverse events were computed, discussed, and evaluated., Results: Thirty-nine cases of EGD adverse events were reported. There were 15 cases (38.5%) of men, and the average age was 58.1±21.6 years. In this period, 314,803 EGDs were performed by the institutes concerned, and the number of adverse events was 0.5 to 2.3 for 10,000 EGDs per year. Perforation occurred in 1 of 31,480 procedures, bleeding in 1 of 39,350 procedures, and respiratory complications in 1 of 157,401 procedures. Trauma to teeth happened in 1:31,480 procedures., Conclusions: This is the first study in Israel about physicians' reports of EGD adverse events. Reporting adverse events in EGD should be encouraged for improving patients' safety.

Introduction: The number of malpractice claims against physicians and health institutes in Israel is increasing continuously, as in the rest of the Western world. This trend became a serious financial burden., Aim: In this study we analyzed reports of gastroenterologists on colonoscopy adverse events to the medical malpractice insurer, as well as complaint/demand for compensation from patients represented by lawyers, between 1 January 2000 and 31 December 2006., Methods: All the reports of physicians associated with colonoscopy adverse events from health institutes covered by Madanes Insurance Group were analyzed and summarized using a specially designed questionnaire. Clinical and epidemiological details about the patients, procedures, and adverse events were coded into an excel sheet, discussed, and evaluated., Results: One hundred and two cases of colonoscopy adverse events were reported. There were 48 cases of men (47.1%) and the average age was 69.9±12.90 years. In this period of time 252 064 colonoscopies were performed by the institutes in the sampling frame, and the number of adverse events was on average 4.0 (between 2.8 and 6.2) for 10 000 colonoscopies. The difference between the years was not statistically significant. Perforation occurred in one of 2864 procedures, bleeding in one of 29 007 procedures, and respiratory complications in one of 50 412 procedures., Conclusion: This is the first study in Israel based on physicians' reports of colonoscopic adverse events. The picture is optimistic, as the rate of complications is low, and the data encourage early detection and reporting.

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.

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.