CMPA research is published in peer-reviewed medical and science journals, and informs collaborative research initiatives.
Are you a CMPA member doing research for education or quality improvement?
Collaborate with us.
Browse published articles and reports
Physicians in practice
Published articles
Exploring the dynamics of physician-patient relationships: Factors affecting patient satisfaction and complaints
This review identifies the factors influencing the relationship between physicians and patients that can lead to patients' dissatisfaction and medical complaints.
View abstract
This review identifies the factors influencing the relationship between physicians and patients that can lead to patients' dissatisfaction and medical complaints. Utilizing a systemic approach 92 studies were retrieved which included quantitative, qualitative, and mixed method studies. Through a thematic analysis of the literature, we identified three interrelated main themes that can influence the relationship between physicians and patients, patients' satisfaction, and the decision to file a medico-legal complaint. The main themes include patient and physician characteristics; the interpersonal relationship between physicians and patients; and the health care system and policies, with relevant subthemes. These themes are demonstrated in a descriptive model. The review suggests areas of focus for physicians who may wish to increase their awareness around the potential sources of relational problems with their patients. Identifying these issues may assist in improvements in the therapeutic relationship with patients, can reduce their medico-legal risk, and enhance the quality of their clinical practice. The findings can also be utilized to support andragogical principles for medical learners. The article can serve as a structured framework to identify potential problems and gaps to design and test effective interventions to mitigate these potential relational problems between physician-patient.
View reference
Mostafapour M, Fortier JH, Garber G. Exploring the dynamics of physician-patient relationships: Factors affecting patient satisfaction and complaints. Journal of Healthcare Risk Management [Internet]. 2024 May 5 [cited 2024 May 15]. Available from: https://onlinelibrary.wiley.com/doi/10.1002/jhrm.21567
Resource issues in the emergency department
This blogpost provides information about how physicians can minimize their medico-legal risk when providing care in under-resourced emergency departments.
View reference
Zaslow J, Lee S. Resource issues in the emergency department. CanadiEMs [Internet]. 2024 Apr 16 [cited 2024 May 1]. Available from: https://canadiem.org/hiquips-resource-issues-in-the-emergency-department/
Medico-legal risks of point-of-care ultrasound: a closed case analysis of Canadian Medical Protective Association medico-legal cases
This research paper analyzes CMPA data to identify medico-legal cases arising from the use of point-of-care ultrasound (POCUS).
View abstract
Background: Point-of-care ultrasound (POCUS) has become a core diagnostic tool for many physicians due to its portability, excellent safety profile, and diagnostic utility. Despite its growing use, the potential risks of POCUS use should be considered by providers. We analyzed the Canadian Medical Protective Association (CMPA) repository to identify medico-legal cases arising from the use of POCUS.
Methods: We retrospectively searched the CMPA closed-case repository for cases involving diagnostic POCUS between January 1st, 2012 and December 31st, 2021. Cases included civil-legal actions, medical regulatory authority (College) cases, and hospital complaints. Patient and physician demographics, outcomes, reason for complaint, and expert-identified contributing factors were analyzed.
Results: From 2012 to 2021, there were 58,626 closed medico-legal cases in the CMPA repository with POCUS determined to be a contributing factor for medico-legal action in 15 cases; in all cases the medico-legal outcome was decided against the physicians. The most common reasons for patient complaints were diagnostic error, deficient assessment, and failure to perform a test or intervention. Expert analysis of these cases determined the most common contributing factors for medico-legal action was failure to perform POCUS when indicated (7 cases, 47%); however, medico-legal action also resulted from diagnostic error, incorrect sonographic approach, deficient assessment, inadequate skill, inadequate documentation, or inadequate reporting.
Conclusions: Although the most common reason associated with the medico-legal action in these cases is failure to perform POCUS when indicated, inappropriate use of POCUS may lead to medico-legal action. Due to limitations in granularity of data, the exact number of civil-legal, College cases, and hospital complaints for each contributing factor is unavailable. To enhance patient care and mitigate risk for providers, POCUS should be carefully integrated with other clinical information, performed by providers with adequate skill, and carefully documented.
View reference
Prager R, Wu D, Garber G, Finestone PJ, Zang C, Aslanova R, Arntfield R. Medico-legal risks of point-of-care ultrasound: a closed-case analysis of Canadian Medical Protective Association medico-legal cases. The Ultrasound Journal. 2024 Feb 23; 16, 16. https://doi.org/10.1186/s13089-024-00364-7
Medico-legal cases associated with older physicians’ cognitive ability to practice medicine
This study examines the potential medico-legal consequences of physicians with cognitive impairments.
View abstract
Background: Dementia increases as individuals age. Aging physicians represent a growing population. Studies have demonstrated there are physicians with cognitive impairments practicing medicine. The medico-legal consequences of physicians with cognitive impairments have not been investigated.
Methods: The Canadian Medical Protective Association (CMPA) is a national medical association with 108,000 members who advise and assist doctors with medico-legal matters. They maintain a national repository of legal actions and complaints to regulatory bodies and hospitals. We looked at civil-legal and regulatory college cases closed over a 10-year period associated with physicians aged ≥55. A word search of the cases was conducted using “Dementia, Alzheimer, Cognitive impairment, Cognitive decline, Memory loss, Memory issues, Fit for/to practice.”
Results: The CMPA closed 67,566 cases between 2012 and 2021 and 16% (10,599) involved members ≥55. A mixed methodology approach identified 65 cases associated with physician's cognitive ability to practice medicine. Of these 65 cases, the average age of physician was 71.3 (56.1–88.5). The proportion of cases where concern was associated with a physician's cognitive ability to practice medicine increased, from 0.2% of cases in 55–60-year-olds, to 7.7% in physicians over 80.
Interpretation: As physicians age, concerns about cognitive impairment are more likely to contribute to medico-legal matters.
View reference
Casey G, Lemay K, Ji J, Yang Q, MacIntyre A, Heroux D, Garber G. Medico-legal cases associated with older physicians’ cognitive ability to practice medicine. Journal of Healthcare Risk Management [Internet]. 2023 November 22 [cited 2023 December 5]. Available from: https://onlinelibrary.wiley.com/doi/10.1002/jhrm.21562
Family physicians’ questions about the COVID-19 pandemic: a content analysis of 2,272 helpline calls
This analysis of family physician calls to the CMPA’s helpline provides insights into family physicians' challenges and experiences during the pandemic.
View abstract
Background: During the COVID-19 pandemic, family physicians faced challenges including travel restrictions for patients, lockdowns, diagnostic testing delays, and changing public health guidelines. Given that 95% of Canadian physicians are members of the Canadian Medical Protective Association (CMPA), the CMPA’s telephone helpline — which offers peer-to-peer support — provides valuable insights into family physicians’ experiences during the pandemic.
Methods: We used a content analysis approach to identify and understand family physicians’ questions and concerns related to the COVID-19 pandemic expressed during calls to the Canadian Medical Protective Association (CMPA) telephone helpline. Calls were classified with preliminary codes and subsequently organized into themes. We collected aggregated data on calls, including province, call date, and whether the physician self-identified having hospital-based activities as part of their practice. Findings from the analysis were explored alongside family physician calls per month (call volume).
Results: Between 01 and 2020 and 31 December 2021, 2,272 family physician calls related to the pandemic were included for content analysis. We identified six major themes across these calls: challenging patient interactions; COVID-related care; the impact of the pandemic on the healthcare system; virtual care; physician obligations and rights; and public health matters. COVID-related call volumes were highest early in the pandemic especially among physicians without major hospital affiliation when family physicians practiced with little guidance on how to balance patient care and scarce resources in the face of a novel pandemic.
Conclusions: This research provides unique insight on the effects the COVID-19 pandemic had on family medicine in Canada. These results provide insights on the needs and information gaps of family physicians in a public health crisis and can inform preparedness efforts by public health agencies, professional organizations, educators, and practitioners.
View reference
MacDougall A, Fortier JH, Zhang C, Ehrat C, Best K, Blois H, Garber G. Family physicians’ questions about the COVID-19 pandemic: a content analysis of 2,272 helpline calls. BMC Primary Care 24, 192 (2023). doi: 10.1186/s12875-023-02147-w
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.
View abstract
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?
View reference
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.
View abstract
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.
View reference
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.
View abstract
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.
View reference
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.
View reference
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.
View reference
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.
View reference
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.
View reference
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.
View reference
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.
View reference
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.
View reference
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.
View reference
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.
View reference
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.
View reference
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.
View reference
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
Characteristics and contributing factors of diagnostic error in surgery: Analysis of closed medico-legal cases and complaints in Canada
This analysis seeks to characterize diagnostic error in the preoperative, intraoperative, and postoperative surgical phases, describe their contributing factors, and quantify their impact related to patient harm.
View abstract
Background: Diagnostic errors lead to significant patient harm; however, most research has been conducted in non-surgical disciplines. We sought to characterize diagnostic error in the pre-, intra-, and post-operative surgical phases, describe their contributing factors, and quantify their impact related to patient harm.
Methods: We performed a retrospective analysis of closed medico-legal cases and complaints using a database representing over 95% of all Canadian physicians. We included cases if they involved a legal action or complaint that closed between 2014 and 2018 and involved a diagnostic error assigned by peer expert review to a surgeon.
Results: We identified 387 surgical cases that involved a diagnostic error. The surgical specialties most often associated with diagnostic error were general surgery (n = 151, 39.0%), gynecology (n = 71, 18.3%), and orthopedic surgery (n = 48, 12.4%), but most surgical specialties were represented. Errors occurred more often in the postoperative phase (n = 171, 44.2%) than in the pre- (n = 127, 32.8%) or intra-operative (n = 120, 31.0%) phases of surgical care. More than 80% of the contributing factors for diagnostic errors were related to providers, with clinical decision-making being the principal contributing factor. Half of the contributing factors were related to the health care team (n = 194, 50.1%), the most common of which was communication breakdown. More than half of patients involved in a surgical diagnostic error experienced at least moderate harm, with 1 in 7 cases resulting in death.
Conclusions: In our cohort, diagnostic errors occurred in most surgical disciplines and across all surgical phases of care; contributing factors were commonly attributed to provider clinical decision-making and communication breakdown. Surgical patient safety efforts should include diagnostic errors with a focus on understanding and reducing errors in surgical clinical decision-making and improving communication.
View reference
Kwan JL, Calder LA, Bowman CL, MacIntyre A, Mimeault R, Honey L, Dunn C, Garber G, Singh H. Characteristics and contributing factors of diagnostic error in surgery: Analysis of closed medico-legal cases and complaints in Canada. Canadian Journal of Surgery [Internet]. 2024 February 6, 67 (1) E58-E65. doi: 10.1503/cjs.003523
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.
View reference
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.
View reference
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.
View reference
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.
View reference
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
Assessing adverse outcomes and learning needs in Canadian psychiatric independent medical examinations
This review addresses the deficit of literature on the risks of independent medical examinations (IMEs) and the learning needs of psychiatrists in this area.
View abstract
Despite the importance of independent medical examinations (IMEs), there is virtually no literature on the risks to the IME assessor nor the learning needs of psychiatrists in this area. To address this deficit, a retrospective chart review of nearly 38,000 cases from the Canadian Medical Protective Association (CMPA) identified 108 files involving complaints or legal actions against psychiatrists performing IMEs. Most complaints identified by the CMPA were to regulatory bodies, including biased opinion, inadequate assessment, inappropriately relying on a requester’s information without independent evaluation, nonadherence to regulatory body policies, cursory documentation lacking relevant details, and communication breakdowns. A survey by the Canadian Academy of Psychiatry and the Law (CAPL) and the Canadian Psychiatric Association (CPA) had 306 Canadian psychiatrist respondents. About 37 percent of psychiatrists completing IMEs reported medico-legal consequences, including complaints to regulatory authorities. Only 40 percent of those doing IMEs and 20 percent of all psychiatrists had formal training in doing IMEs. The studies confirm that despite a low but important risk of medico-legal consequences, many psychiatrists performing IMEs do not have formalized training. Using the new CAPL Canadian Guidelines for Forensic Psychiatry Assessment and Report Writing is a step to reduce the risk of such evaluations.
View reference
Booth BD, Waldman JC, Fortier JH, Garber G, Hardy K, Lemay K, Liu R, Tomita TM, Ramshaw LAL. Assessing adverse outcomes and learning needs in Canadian psychiatric independent medical examinations. The Journal of the American Academy of Psychiatry and the Law [Internet]. 2024 Mar 1;52(1). doi:10.29158/JAAPL.230116-23
Medico-legal risk of infectious disease physicians in Canada: A retrospective review
This study identifies the causes of medico-legal risk for infectious disease specialists in Canada, with the goal of improving patient safety and outcomes.
View abstract
Objectives: There is little known about the medico-legal risk for infectious disease specialists in Canada. The objective of this study was to identify the causes of these medico-legal risks with the goal of improving patient safety and outcomes.
Methods: A 10-year retrospective analysis of Canadian Medical Protective Association (CMPA) closed medico-legal cases from 2012 to 2021 was performed. Peer expert criticism was used to identify factors that contributed to the medico-legal cases at the provider, team or system level, and were contrasted with the patient complaint.
Results: During the study period there were 571 infectious disease physician members of the CMPA. There were 96 patient medico-legal cases: 45 College complaints, 40 civil legal matters and 11 hospital complaints. Ten cases were associated with severe patient harm or death. Patients were most likely to complain about perceived deficient assessments (54%), diagnostic errors (53%), inadequate monitoring or follow up (20%) and unprofessional manner (20%). In contrast, peer experts were most critical of the areas of diagnostic assessment (20%), deficient assessment (10%), failure to perform test/intervention (8%) and failure to refer (6%).
Conclusions: While infectious disease physicians tend to have lower medico-legal risks compared to other healthcare providers, these risks still do exist. This descriptive study provides insights into the types of cases, presenting conditions, and patient allegations associated with their practice.
View reference
Pacheco K, Ji J, Barbosa K, Lemay K, Fortier JH, Garber G. Medico-legal risk of infectious disease physicians in Canada: A retrospective review. Journal of the Association of Medical Microbiology and Infectious Disease Canada [Online] 8, 4 pp. 319-327 (December 2023). doi: 10.3138/jammi-2023-0022
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.
View abstract
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.
View reference
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.
View reference
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
Lessons learned from examination of Canadian medico-legal cases related to interventional therapies for chronic pain management
This research paper investigates patient safety incidents from injection therapies used to treat chronic pain, identifying themes that could be used to improve patient safety.
View reference
MacLean E, Garber G, Barbosa K, Liu R, Verge A, Mukhida K. Lessons learned from examination of Canadian medico-legal cases related to interventional therapies for chronic pain management. Canadian Journal of Anesthesia. 2023 Jul 31;70,1504-1515. https://doi.org/10.1007/s12630-023-02531-1
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.
View reference
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.
View reference
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.
View reference
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