8 minutes
Published: January 2024
At the end of 2022, 213 CMPA members were cardiac surgeons (Type of Work 91). In a 5-year period (2018 – 2022)1, 24.3% of cardiac surgeons were named in 1 new medico-legal case (legal action, College, or hospital complaint), and another 9.4% were named in 2 or more new cases.
On average, 10.4% of cardiac surgeons were named in 1 new medico-legal case, and an additional 0.7% were named in 2 or more new cases annually across this 5-year period1.
The graphs below compare the 10-year trends in cardiac surgeons’ medico-legal experiences with those of all surgical specialties.
What are the relative risks of a medico-legal case for cardiac surgeons?
- Cardiac surgeons, College(n=95)
- Cardiac surgeons, Legal(n=80)
- All surgical specialists, College(n=7,159)
- All surgical specialists, Legal(n=4,350)
Between 2013 and 2022, the rate of College matters2 for cardiac surgeons had significantly lower rates (p<.0001) than the rate for all surgical specialties.
Compared to all surgical specialties, the rate of civil legal cases for cardiac surgeons showed more fluctuations. Overall, cardiac surgeons have a significantly lower rate (p=0.04) during the recent 10 years.
The following sections describe the findings based on the 111 cases with peer expert criticism, including civil legal actions, College, and hospital matters involving cardiac surgeons that were closed by the CMPA between 2013 and 2022.
What are the most common patient complaints and peer expert criticisms?3 (n=111)
| Deficient assessment |
49 |
10 |
| Diagnostic error |
36 |
12 |
| Inadequate monitoring or follow-up |
34 |
6 |
| Inadequate consent process |
31 |
9 |
| Injury associated with healthcare delivery |
25 |
22 |
| Failure to perform test or intervention |
20 |
10 |
| Communication breakdown with the patient |
15 |
4 |
| Insufficient knowledge or skill |
12 |
5 |
| Failure to refer |
9 |
3 |
| Poor decision-making regarding management |
9 |
2 |
Complaints are a reflection of the patient’s perception that a problem occurred during care. These complaints are not always supported by peer expert opinion. Peer experts may not be critical of the care provided, or may have criticisms that are not part of the patient allegation.
What are the most frequent interventions with peer expert criticism? (n=111)
- Coronary artery bypass graft (45)
- Aortic valve replacement (19)
- Mitral valve repair (8)
- Implantation of implantable cardioverter defibrillator or pacemaker (7)
- Mitral valve replacement (5)
Intervention frequencies among medico-legal cases are likely representative of cardiac surgeons’ practice patterns and do not necessarily reflect high-risk interventions.
Peer expert criticisms
Pre-operative phase
- Inadequate consent process
Intra-operative phase
- Deficient assessment
- Failure to perform test or intervention
- Misidentification of anatomy
Post-operative phase
- Inadequate monitoring or follow-up
- Communication breakdown among physicians
- Inadequate documentation
In the 111 cases, 24 patients suffered an injury during a procedure. For example:
- A cardiac surgeon’s failure to order follow-up imaging to ensure correct placement of a pericardial drain, and a nurse’s failure to monitor the patient, led to the death of a patient, due to a hemorrhage from a punctured heart.
- A patient died when a pericardial drain insertion led to a bowel herniation and perforation during an aortic valve replacement. A peer expert provided criticism regarding the poorly documented consent discussion, especially regarding the risks of drain insertion.
In addition, 13 patients experienced a diagnostic error. For example:
- The cardiac surgeon did not follow up on a diagnosis of lung cancer that was based on a pre-operative x-ray. The hospital did not have appropriate protocol in place to ensure the most responsible physician (MRP) received abnormal imaging.
- A misread CT scan led to a post-partum patient undergoing unnecessary surgery for an aortic dissection. Transesophageal echocardiogram was not available at the facility.
Risk reduction reminders
The following risk management considerations have been identified for cardiac surgeons.
Pre-operative
- Gather an appropriate history, including co-morbidities and current medications, and conduct an appropriate systematic physical examination with vital signs. Include a review of current status and investigations.
- Consider any relevant patient risk factors, including co-morbidities and history, that could have an impact on the patient's management, and consider further specialist consultation if indicated.
- Consent discussions for surgery or procedures should provide comprehensive information on material risks, benefits, alternatives, expected outcomes, and potential complications related to pre-existing conditions. Allow patients (and their family or caregivers, where appropriate) to ask questions. Thoroughly document the discussion in the medical record.
Intra-operative
- Consider the risks of intra-operative injuries during all phases of surgical care. Take precautions to protect vital structures such as nerves and vasculature, and document any efforts to visualize or protect these structures.
- Consider altering techniques or consulting a colleague when difficulties are encountered during surgery.
Post-operative
- Provide comprehensive discharge instructions to patients or caregivers (where appropriate), both verbally and in writing, including postoperative instructions, wound care, medications, follow-up care, symptoms and signs to monitor, and guidance on when to seek medical attention. Provide clear information on when and who to contact in case of complications.
Limitations
The numbers provided in this report are based on CMPA medico-legal data. CMPA medico-legal cases represent a small portion of patient safety incidents. Many factors influence a person’s decision to pursue a case or file a complaint, and these factors vary greatly by context. Thus, while medico-legal cases can be a rich source for important themes, they cannot be considered representative of patient safety incidents overall.
Now that you know your risk…
Mitigate your medico-legal risk with CMPA Learning resources.
- CMPA research:
- CMPA eLearning:
- CMPA workshops:
Questions?
Please contact [email protected]
Notes
-
It takes an average of 2-3 years for a patient safety incident to progress into a medico-legal case. As a result, newly opened cases may reflect incidents that occurred in previous years.
-
Physicians voluntarily report College matters to the CMPA. Therefore, these cases do not represent a complete picture of all such cases in Canada.
-
Peer experts refer to physicians who interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided. They are typically of similar training and experience as the physicians whose care they are reviewing.
