CMPA research is published in peer-reviewed medical and science journals, and informs collaborative research initiatives.
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Physicians in practice
Published articles
Identifying a list of healthcare “never events” to effect system change: A systematic review and narrative synthesis
This systematic review aims to identify the most serious and preventable “never events” to support efforts to improve patient safety.
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Never events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable?
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Bowman CL, de Gorter R, Zaslow J, Fortier JH, Garber G. Identifying a list of healthcare “never events” to effect system change: A systematic review and narrative synthesis. British Medical Journal (BMJ) Open Quality [Internet]. 2023 June 26;12:e002264. doi: 10.1136/bmjoq-2023-002264
Diagnostic delays in sepsis: Lessons learned from a retrospective study of Canadian medico-legal claims
This article aims to identify areas of focus to assist physicians with the early recognition of sepsis, using medico-legal data.
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Objective: Although rapid treatment improves outcomes for patients presenting with sepsis, early detection can be difficult, especially in otherwise healthy adults. Using medico-legal data, we aimed to identify areas of focus to assist with early recognition of sepsis.
Subjects: The study included cases closed between 2011-2020 that had documented peer expert criticism of a diagnostic issue related to sepsis or relevant infections.
Conclusions: Sepsis continues to be a challenging diagnosis for clinicians. Multiple visits to outpatient care may be an early warning sign requiring vigilance in the patient assessment.
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Neilson H, Fortier J, Finestone PJ, Ogilby C, Liu R, Bridges E, Garber G. Diagnostic delays in sepsis: Lessons learned from a retrospective study of Canadian medico-legal claims. Critical Care Explorations [Internet]. 2023 Feb 3 [cited 2023 Feb 6];5(2):E0841. Available from: https://journals.lww.com/ccejournal/Fulltext/2023/02000/Diagnostic_Delays_in_Sepsis__Lessons_Learned_From.2.aspx
Defining healthcare never events to effect system change: A protocol for systematic review
This article outlines the protocol for a forthcoming systematic review that will identify events that are consistently or frequently labelled as never events, work that will allow organizations and researchers to direct resources to the events most amenable to reduction efforts.
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A never event is the most egregious of patient safety incidents. It refers to events that should theoretically never happen, such as amputating the wrong limb.
The term “never event” is used around the world by a variety of medical and patient safety organizations and is synonymous with sentinel events and serious reportable events. Unfortunately, there is little consensus about which events, in particular, are never events. These differing lists hinder potential collaboration or large-scale analyses.
A recent systematic review by Hegarty et al. (2020) identified the need for a standardized definition for serious reportable events. The objective of our systematic review is to build on this by identifying those events that are consistently or frequently labelled as never events, which will allow organizations and researchers to direct resources to the events most amenable to reduction efforts.
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Zaslow J, Fortier J, Bowman C, de Gorter R, Tsai E, Desai D, O’Neill P, Mimeault R, Garber G. Defining healthcare never events to effect system change: A protocol for systematic review. PLOS ONE [Internet]. 2022 Dec 15 [cited 2023 Jan 9];17(12)E0279113. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0279113
Physician questions and concerns related to COVID-19: A content analysis of advice calls to a medico-legal helpline
This paper evaluates themes across calls made by physicians to a medico-legal helpline during the first eighteen months of the COVID-19 pandemic. It explores associations between the volume and content of calls, and the geography and intensity of the pandemic.
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Fortier JH, McDougall A, Zhang C, Ehrat C, Ficara G, Cranney A, Garber G. COVID-19 related physician questions and concerns: A content analysis of 3800 advice calls to a medico-legal helpline. CMAJ Open [Internet]. 2022 Aug 2 [cited 2022 Aug 2];10(3):E714-20. Available from: http://www.cmajopen.ca/lookup/doi/10.9778/cmajo.20210256
Optimizing your diagnostic reasoning – Themes from CMPA medico-legal cases
This blog post provides an understanding of some common causes of diagnostic error. Diagnostic errors are an inherent risk of clinical practice and a common theme in CMPA closed cases. Even when errors are identified, learning from them can be challenging.
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Zaslow J, Lee S. Optimizing your diagnostic reasoning – themes from CMPA medico-legal cases. HiQuiPs [Internet]. 2022 Jul 6 [cited 2022 Jul 11]; Available from: https://www.hiquips.com/post/optimizing-diagnostic-reasoning-cmpa-medico-legal-cases
Using medicolegal data to support safe medical care: A contributing factor coding framework
This methodological paper discusses a new patient safety-informed framework developed by the CMPA, which acknowledges the effects of team, organizational, and system factors, in addition to physician care. This new approach revolutionizes the way the CMPA codes its medical-legal data, and improves understanding of the many factors that contribute to patient safety events.
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McCleery A, Devenny K, Ogilby C, Dunn C, Steen A, Whyte E, et al. Using medicolegal data to support safe medical care: a contributing factor coding framework. J Healthc Risk Manag [Internet]. 2018 Aug 3 [cited 2018 Nov 19]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/30074677
Improved hospital safety performance and reduced medicolegal risk: An ecological study using 2 Canadian databases
This paper analyzes two Canadian databases, the CMPA and the Discharge Abstract Database, to determine if there was a relationship between in-hospital patient safety events and medico-legal cases involving physicians in Canada. This study is novel in that there are very few like it based on Canadian data and it shows the practical use for medico-legal and patient safety data, which can be used to improve patient safety and quality of care.
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Yang Q, Zhang C, Hines K, Calder LA. Improved hospital safety performance and reduced medicolegal risk: an ecological study using 2 Canadian databases. CMAJ Open [Internet]. 2018 Nov 19 [cited 2018 Nov 23];6(4):E561–6. Available from: http://cmajopen.ca/lookup/doi/10.9778/cmajo.20180077
Physicians in training (residents and fellows)
Published articles
Patterns and trends among physicians-in-training named in civil legal cases
This study presents civil legal case rates for physician-in-training in Canada. It analyses case rates over a 25-year period, describing case duration, medico-legal outcome, and patient harm. It also examines physician specialties and practice characteristics in a subset of cases.
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McDougall A, Zhang C, Yang Q, Taylor T, Neilson HK, Nuth J, Tsai E, Lee S, Lefebvre G, Calder LA. Patterns and trends among physicians-in-training named in civil legal cases. CMAJ Open [Internet]. 2022 Sept 13 [cited 2022 Sept 13];10(3)E781-E788. Available from: https://www.cmajopen.ca/content/10/3/E781
College complaints against resident physicians in Canada: A retrospective analysis of CMPA data from 2013 to 2017
This paper analyzes the trends and nature of College complaints filed against resident physicians, and examines the rates of College complaints involving residents relative to rates for other CMPA members.
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Crosbie C, McDougall A, Pangli H, Abu-Laban RB, Calder LA. College complaints against resident physicians in Canada: a retrospective analysis of CMPA data from 2013 to 2017. CMAJ Open. 2022 Jan 18;10(1):E35-E42. doi: 10.9778/cmajo.20210026
The medico-legal helpline: A content analysis of postgraduate medical trainee advice calls
This paper used CMPA advice calls to explore the frequency of and reasons behind why trainees called the Association. Our study found that physicians-in-training are calling the CMPA with increasing frequency, with the most common issue relating to managing confidential information, complex care situations, academic matters and patient safety incidents.
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McDougall A, Zaslow J, Zhang C, Yang Q, Nuth J, Tsai E, Lee S, Lefebvre G, Calder L. The medico-legal helpline: A content analysis of postgraduate medical trainee advice calls. Medical Education. 2020; 00:1-7.
Obstetrics
Published articles
Promoting best practices in Assisted Human Reproduction
This retrospective analysis of CMPA data identifies contributing factors to medico-legal risks for Canadian physicians providing Assisted Human Reproduction (AHR) services.
Note: A subscription is required to access this article.
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Payant L, Finestone PJ, Ji J, Garber G, Leader A. Promoting best practices in Assisted Human Reproduction. Journal of Obstetrics and Gynaecology Canada [Internet]. 2023 June 12 [cited 2023 June 23]; Available from: https://www.jogc.com/article/S1701-2163(23)00434-6/fulltext#secsectitle0080
Quality improvement initiatives in areas of practice with high medical-legal risk in obstetrical care: A systematic review
This paper reviews published evaluations of obstetrical quality improvement initiatives and identifies those that addressed areas of high medical-legal risk for physicians providing obstetrical care.
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Calder LA, Bowman CL, De Gorter R, Wright E, Yang Q, Lefebvre G. 2020. Quality improvement initiatives in areas of practice with high medical-legal risk in obstetrical care: A systematic review. Unpublished manuscript, Canadian Medical Protective Association.
Implementing obstetrics quality improvement, driven by medico-legal risk, is associated with improved workplace culture
This paper reports the findings from a collaborative, quality improvement program based on CMPA knowledge of medico-legal risk in obstetrics, and the impact of the program on workplace culture.
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Lefebvre G, Honey L, Hines K, Keough A, Roye C, Bellemare S, Piscione TD, Falconer A, Shepherd L, Thorne S, Wallace G, Calder LA. Implementing Obstetrics Quality Improvement, Driven by Medico-legal Risk, is Associated With Improved Workplace Culture. J Obstet Gynaecol Canada [Internet]. 2020 January [cited 2020 January 14]; 42(1): 38-47.e5. Available from: https://doi.org/10.1016/j.jogc.2019.05.011
A quality indicator framework for high-risk areas in obstetrical care
This study describes the development of a set of quality improvement indicators for areas of practice associated with increased medical-legal risk in order to support measurable improvements in obstetrical practice. It illustrates the importance of balancing measures when creating quality metrics, as well as providing practical quality indicators for quality improvement teams and researchers to engage in improvements in obstetrics quality of care.
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Calder LA, Bowman CL, Yang Q, Gondocz T, Young C, Zhang C, MacIntyre A, Darling R, O’Neill JP, Roye C, Lefebvre, G. 2019. A quality indicator framework for high-risk areas in obstetrical care. Unpublished manuscript, Canadian Medical Protective Association.
Reports
Recommendations from a national panel on quality improvement in obstetrics
This paper describes the recommendations of a national panel on quality improvement in obstetrics to identify priorities for action in five areas of greatest medico-legal risk.
Delivery in focus: Strengthening obstetrical care in Canada
This report by the CMPA and HIROC aims to advance patient safety and quality improvement in obstetrical care by identifying key areas of risk and offering mitigation strategies for healthcare providers and organizations.
Obstetrics services in Canada: Advancing quality and strengthening safety
A collaborative report by Accreditation Canada, the Healthcare Insurance Reciprocal of Canada (HIROC), the Canadian Medical Protective Association (CMPA), and Salus Global Corporation that profiles the quality and safety of obstetrics services in Canada from 2004 to 2015.
Surgery
Published articles
Trends and contributing factors in medicolegal cases involving spine surgery
This paper describes closed medico-legal cases involving physicians and spine surgery in Canada. While previous studies have applied a medico-legal lens to their analyses, this study also applies a quality improvement and patient safety lens.
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Calder LA, Whyte EM, Neilson HK, et al. Trends and Contributing Factors in Medicolegal Cases Involving Spine Surgery. Spine. 2022 Jun 1;47(11):E469-E476. doi: 10.1097/BRS.0000000000004332
Medico-legal closed case trends in Canadian plastic surgery: A retrospective descriptive study
This paper provides a retrospective descriptive analysis of the characteristics of medico-legal cases involving specialist plastic surgeons over a 5-year period. This study describes the medico-legal landscape in Canadian cosmetic and non-cosmetic plastic surgery, highlighting the importance of strong physician–patient communication, patient education, and informed consent in preventing complaints.
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Zhang Z, Calder LA, Finestone PJ, Liu R, Bucevska M, Arneja JS. Medico-legal closed case trends in Canadian plastic surgery: a Retrospective Descriptive Study. PRS Global Open. 2021; 9(8): e3754. doi: 10.1097/GOX.0000000000003754
Intraoperative injuries from abdominopelvic surgery: An analysis of national medicolegal data
This 5-year analysis of CMPA closed cases described the frequency and types of injury, clinical management and outcomes, and the contributing factors—both technical and nontechnical including the impact of documenting informed consent.
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Lefebvre G, Devenny KA, Héroux DL, Bowman CL, Neilson HK, Mimeault R, Singh SS, Calder LA. Intraoperative injuries from abdominopelvic surgery: An analysis of national medicolegal data. Can J Surg. 2021 Mar 5;64(2):E127-E134. doi: 10.1503/cjs.010219
Surgical fires and burns: A 5-year analysis of medico-legal cases
This paper provides a retrospective descriptive analysis of the contributing factors in medico-legal cases involving surgical fires and burns in Canada over a 5-year period. This study highlights a need for improved surgical safety interventions to address surgical fires and burns.
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Calder L, Héroux D, Bernard C, Liu R, Gilchrist A, Neilson HK, Gilchrist AD, Fish J. Surgical fires and burns: a 5-year analysis of medico-legal cases. J Burn Care Res. 2019:1-7. [epub ahead of print]
Reports
Surgical safety in Canada: A 10-year review of CMPA and HIROC medical-legal data
This is a retrospective analysis of Canadian surgical incident data, which includes recommendations to advance knowledge in patient safety concepts and lead to system and practice improvements.
Surgical safety checklists: A review of medical-legal data
This review of CMPA medico-legal data points to the continued relevance of the clinical issues that the Surgical Safety Checklist (SSCL) is intended to address, highlights some of the barriers to its effective use, and identifies priority areas for system and individual practice improvements.
Surgical safety checklists: A review of medical-legal data [PDF]
Other specialties
Published articles
Medico-legal issues related to emergency physicians’ documentation in Canadian emergency departments
This study provides examples of documentation issues attributed to physicians practicing emergency medicine, as identified by peer experts in medico-legal cases in Canada.
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Objectives: Physician documentation plays a central role in the delivery of safe patient care. It describes a physician’s clinical decision-making and supports essential communication between healthcare providers within the patient’s circle of care. Good documentation can potentially also decrease a physicians’ medico-legal risk. This study provides examples of documentation issues attributed to physicians practicing emergency medicine as identified by peer experts in civil legal actions, regulatory authority complaints (College) and hospital complaints (collectively, medico-legal cases) in Canada.
Methods: We conducted a descriptive study and content analysis of medico-legal cases involving emergency department physicians from a national repository at the Canadian Medical Protective Association. Cases with peer expert criticism of an emergency physicians’ documentation, which were closed between 2016 and 2020, and occurred in an emergency department were included in our analysis.
Results: Of the 1,628 cases involving emergency medicine, our inclusion criteria identified that absent or insufficiently detailed documentation was present in 24% of cases (391/1,628). A detailed review of 20% of cases (79/391), selected randomly, found that documentation issues were most often associated with the assessment and investigation stage of care. This pertained to documenting details of the clinical examination, relevant medical history, diagnosis, and differential diagnosis.
Conclusions: For physicians practicing emergency medicine, criticism of documentation was frequently observed in medico-legal cases. Based on the findings of this study and the expert criticism related to documentation, emergency medicine physicians may consider reflecting upon their documentation of the care provided to determine if their documentation provides a clear and accurate chronicle of the care and the rationale for their clinical decisions.
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Smith JD, Lemay K, Lee S, Nuth J, Ji J, Montague K, Garber G. Medico-legal issues related to emergency physicians’ documentation in Canadian emergency departments. Canadian Journal of Emergency Medicine [Internet]. 2023 August 30 [cited 2023 September 15]. Available from: https://link.springer.com/article/10.1007/s43678-023-00576-1
Medico-legal cases in breast imaging in Canada: A trend analysis
This study evaluates the key medico-legal issues of breast imaging in Canada and their implications for healthcare providers and patient safety.
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Seely JM, Payant L, Zhang C, Aslanova R, Chothia S, MacIntyre A, Trop I, Yang Q, Garber G, Patlas M. Medico-legal cases in breast imaging in Canada: A trend analysis. Canadian Association of Radiologists Journal [Internet]. 2023 August 5 [cited 2023 Aug 22];0(0). doi:10.1177/08465371231193366
Medico-legal risk and use of medical directives in the emergency department
This study describes and analyzes factors associated with medico-legal risk in cases involving medical directives in the emergency department.
Note: A subscription is required to access this article.
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Cortel-LeBlanc MA, Lemay K, Woods S, Bakewell F, Liu R, Garber G. Medico-legal risk and use of medical directives in the emergency department. Canadian Journal of Emergency Medicine [Internet]. 2023 May 12 [cited 2023 May 24]; Available from: https://link.springer.com/article/10.1007/s43678-023-00522-1
Medico-legal cases involving cardiologists and cardiac test underuse or overuse
This study showed that across 10 years of closed CMPA medico-legal cases, there were no peer expert criticisms of cardiologists for cardiac diagnostic test overuse, despite potential harms from overuse. Criticisms of cardiac test underuse were rare and related to issues with diagnosing symptomatic patients.
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Calder LA, Neilson HK, Whyte EM, Ji J, Bhatia RS. Medico-legal cases involving cardiologists and cardiac test underuse or overuse. CJC Open. 2020 Dec 1;3(4):434-441. doi: 10.1016/j.cjco.2020.11.018
Anesthesiology airway-related medicolegal cases from the Canadian Medical Protection Association
This paper provides a retrospective descriptive analysis of the contributing factors in medico-legal cases involving specialist anesthesiologists where airway management was a central issue, highlighting the importance of adherence to clinical practice guidelines.
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Crosby ET, Duggan L, Finestone P, Liu R, De Gorter R, Calder LA. Anesthesiology airway-related medicolegal cases from the Canadian Medical Protection Association. Can J Anesth/J Can Anesth [Internet]. 2020 Nov 16 [cited 2020 Dec 9]. Available from: https://doi.org/10.1007/s12630-020-01846-7
