Year : 2007 | Volume
| Issue : 1 | Page : 4
Status of medical liability claims in Saudi Arabia
Anaesthesia Department, King Khalid University Hospital, King Saud University, PO 7805 internal 41, Code 11472, Saudi Arabia
Anaesthesia Department, King Khalid University Hospital, King Saud University, PO 7805 internal 41, Code 11472
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||5-Oct-2009|
| Abstract|| |
Background: The author analyzed the medical malpractice litigation that was referred to the National Medico-legal Committee in order to evaluate the magnitude and underlying factors of the problem in Saudi Arabia.
Patients and Methods: Retrospective analysis of the official records of Medico-legal malpractice claims over the period 1420H-1424H (1999-2003) was performed. The incidence among different medical specialties, location, and final resolution of each claim were identified.
Results: Data analysis revealed an increasing trend of the total number of claims over the study period with a sharp increase in the transition between 1422H and 1423H (2001-2002). The distribution of claims over different medical specialties showed that Obstetrical practice took the lead with 27%, followed by general surgery and subspecialties being represented by 17% each, internal medicine 13%, while pediatrics contributes 10% of the claims, being the least of all is dentistry with 2.5%. The majority of claims were referred to Ministry of Health and Private sectors medical facilities. Most claims were from Riyadh region over the period between 1420H - 1422H (1999-2001), while thereafter on 1423 and 1424H (2002 and 2003) the Holy Capital represents the highest number of claims being referred to the Medico-legal Committee.
Conclusion: Adherence to the standards of medical practice is by far to the best approach to avoid or reduce the incidence of litigation.
Keywords: Medical liability, Anaesthesia, Saudi Arabia
|How to cite this article:|
Al-Saeed A. Status of medical liability claims in Saudi Arabia. Saudi J Anaesth 2007;1:4
| Introduction|| |
Health Care Services in Saudi Arabia have shown a great evolution over the past two decades in both governmental and private sectors. This development in health care was the result of the upgrading technology at the facilities as well as the training and improved experience of the medical practitioners  . However, the increasing number of population together with the increased awareness about health matters resulted in an increasing trend of medical practice litigations  . This is reflected by the number of complaints and claims against health care providers (whether generally as a facility or individually against physicians). Thus, to handle such an impact, it was found necessary to formulate and to set standards and regulations that determine the responsibilities of health care providers towards patients. The Regulations of Medical Practice was settled by the Ministry of Health (MOH) aiming at improving the quality of health care. The Medico-legal Committee (MLC) carries the responsibility of receiving claims and investigating the professional malpractice that resulted in either morbidity or mortality. The process of investigations achieved through reviewing all patient's medical fillings and records as well as an interview of the presumed accused medical staff members, in order to reach a verdict.
Different clinical specialties had been implicated in litigations, being the leading specialty is obstetrical practice followed by different surgical specialties and ends by Anaesthesia, dentistry and by laboratories specifically blood banks.
As an active member of the Medico-legal Committee (MLC) in Riyadh region under the authority of the Ministry of Health (MOH) in Saudi Arabia. I found it is imperative to analyze the malpractice claims from various aspects. This analysis includes the different medical specialties that may hopefully have a rule in updating the regulations of MLC as well as providing useful information to my colleagues from both from the professional and the legal aspects.
| Methods|| |
The raw data for analysis was provided from the official documents of the Medico-legal committee in Riyadh under the authority of the Ministry of Health in Saudi Arabia. The data included all claims against all medical specialties and gathered from the whole Medico-legal subcommittees (6 subcommittees over 1420H - 1422 H, and upgraded to 8 subcommittees thereafter during 1423, 1424 H) covering the various health care regions in the Kingdom of Saudi Arabia. The author and as a member of the MLC in Riyadh region, analyzed the data provided in official documents. The number of cases included in this study does not represent the total number of litigations against different specialties, because there were other cases that were investigated at a lower level and were not included.
Data included the number of claims over the period between (1420 H - 1424 H). The data was provided in tables identifying the following:
Retrospective data analysis was performed in all medical malpractice claims. Further, the rank of the Medical Facility and its geographical location that is involved in the claim in order to overview the quality of health care provided by different sectors in the Kingdom of Saudi Arabia.
- The number of MLC monthly sessions in each region held over the year.
- The number of claims investigated in each subcommittee over the year.
- The justified final decisions of conviction or clearance from the claim.
- The number, medical specialty and qualification of physicians involved .
- The detailed number of physicians, nursing or technicians being convicted or cleared after interrogations.
- The rank of the medical facility involved in the claim.
| Results|| |
Data analysis revealed an increasing trend of the total number of claims in different medical specialties over the study period [Figure 1]. A 21% increase in medical malpractice litigations was noted between 1422H and 1423H (from 569 to 718 claims). The distribution of claims over different medical specialties showed that Obstetrical practice took the lead with 27%, followed by general surgery and subspecialties being represented by 17% each, internal medicine 13%, while pediatrics contributes 10% of the claims, being the least of all is dentistry with 2.5% [Figure 2]. The percentage of Anaesthesia- related malpractice claims in relation to the total number of claims in different specialties were 3.4% (15 out of total 440 claims) and 3.4% (17 / 496) in 1420H and 1421H respectively. A decline was noted in 1422H (11 / 569, 1.9%), 1423H (20 / 718, 2.7%), and 1424H
(17 / 747, 2.2%) [Figure 3]. The percentage of anesthesia - related convictions to the number of total convictions was highest in 1421H (9.1%) and lowest in 1422H and 1424 (6.2% and 6.1% respectively) [Table 1]. The distribution of claims versus different medical centers is shown in [Table 2]. Considering the distribution of the Convicted Decisions against physicians over the different regions of the Kingdom of Saudi Arabia, it was found that the highest number conviction of claims were in Riyadh region during 1420 - 1422, while the Holy Capital took the lead afterward on 1423 and 1424 [Table 3].
| Discussion|| |
An overview of the analyzed data revealed some facts that was hidden while being out of our scope of interest. As an active member of the MLC in Riyadh region being involved in investigation and analysis of different lawsuits and claims in medical care gave me the privilege of offering some insight about the magnitude of the problem from different aspects. First I will start by giving a brief comment regarding the MLC rules and regulations governing the medical practice.
The Process of Medical Litigation:
The process of medical litigations starts once a patient or a member of his/her relatives complains of a medical malpractice from their point of view that ends with a morbidity or mortality. The complaint is directed either to the Ministry of health or the City Government according to the medical facility indulged in the complaint. A process of investigation and interrogation follows within the medical facility with the medical staff either sharing the responsibility or attending the event. The MLC then assigned to follow with a process of thorough review of all documents and medical filling together with interviewing both sides of the claim- the plaintiff and defendant(s), in order to reach a final decision of accusation or clearance from the claim according to the "Regulations of Medical Practice "which is based on professional aspects and governed by Islamic Shariaah law  .
Professional liability as an entity covers 3 different aspects:
1- The Civil liability: This is the responsibility of a physician towards the patient when harm being inflicted as a result of direct action against medical rules from the physician or proven negligence.
2- The Punitive liability: that deals with physicians who violate the rules and regulations of medical practice even with no subsequent harm resulted to the patient.
3- The Disciplinary liability: where a physician failed to meet with professional standards, requirements and ethics  .
Finally claim may end up in warning, financial compensation according to Shariaah law, prohibiting medical practice and withdrawal of medical license or imprisonment in some cases  .
A global view over the analyzed data showed that there was an increasing trend in the total number of litigations over the study period that could be related to the increased number of population as well as the increased number of medical facilities. However, the fact of increased litigations stems from people who became more aware of standard medical care and demanding for it as well. Also, a sharp increase was noted in the transition between 1423H and 1424H which could be explained by the institution of two new committees in the Holy Capital and Ehsaa.
Anesthesia has been classed as a high risk specialty  . This classification was based on facts that the state of hypnosis may result in airway obstruction, pulmonary aspiration or trauma  . Also most the anesthetic drugs have undesirable adverse effects on both cardiovascular and respiratory systems. Further, an anesthetized patient is totally dependent on the anesthetist and equipments for maintenance of his vital activities  .
Thus, my specialty as an anesthetist gave me the urge to further analyze and concentrate on the scope of anesthesia- related malpractice claims and its relation to the total number of claims, which was found to contribute about 3 - 4 %. Nevertheless, if one looks at the relation to the number of finally accused claims and specifically against physicians, this will lead to a higher percentage of anesthesia- related malpractice between 6.1 % - 9.1 % of the totally accused claims. Different articles and meta-analysis studies worldwide have navigated the scope of anesthesia-related malpractice and ends up in solid fact that cardio-respiratory arrest and cerebral damage resulting from hypoxemia is the leading cause that ends in mortality or drastic morbidity  , , , . Oxygen supply to the patient being of the highest concern rather than any defect in alveolar gas exchange or oxygen delivery to the tissues, meaning equipment failure or matters dealing with a compromised upper airway with the inability to adequately ventilate a hypnotized, sedated and/or paralyzed patient  . Neuroaxial deficits resulted after regional anesthesia techniques was the second common cause, but with a wide range of consequences that being simple as transient neurapraxia up to permanent loss of function resulting from peripheral nerve damage or spinal cord injury  . In the western part of the world, lawsuits against intraoperative awareness are not uncommon with its psychological feedback on patients in the postoperative period  , , .
The main aim of giving such details in some of the cases is to widen the scope of anesthetists for matters that may be treated as out of their responsibility and that their main role is only intraoperative management. At the same time, we hope that this will not lead to what is called "defensive medicine" attitude but rather a safe practice of medicine for our patient which is of course our ultimate interest  .
Nonetheless, to mention that ranking and setup of the medical facility plays an important role in the increased incidence for litigations. Data analysis revealed that the MOH and private sectors contributes more than 90% of the total number of claims that referred to the MLC. The MOH hospitals or small clinics covers most of the small cities and that most of these facilities are run by under-trained and under-staffed physicians together with inadequate equipment and supplies, a fact which renders such facilities more prone for malpractice and litigations  . The Private sector despite of the fact that it is mostly well equipped and staffed, yet the reduction of cost is their main consideration which may lead the way to manage with the less than ideal conditions. Further, patients going to the expensive private sector- considering their culture and social class are more demanding for a quality care health service  .
"Polices and Procedures" , "Rules and Regulations" , "Standards of Medical Practice" all grouped falls into the same concern which is quality assured medical service that ensures patient safety. Following standards could also restrict the magnitude of medical errors which had been classified by the Agency for Health Research and Quality as diagnostic error, equipment error, misinterpretation of medical orders or data and finally mismanagement with resultant morbidity as postoperative infections or mismatched blood transfusion.  .
Based on the experience gained by serving in the MLC and after being exposed to different situations during investigation of claims, I thereby could offer my advice based on the actual pitfalls observed in investigating cases and formed the ground of lawsuits.
- Assess your patient thoroughly and ask for consultations of different specialties as to properly prepare your patient to the stress of any intervention.
- Estimate accurately the patient risk and discus it in details with the patient or family members as to be implemented on patient consent before any intervention.
- Clear documentation of every detail (with date and time) is the corner stone that backs you up in case of incidents.
- Follow up your patient closely in the postoperative period especially in risky patients or those situations where Intraoperative events had been encountered.
- Update your professional knowledge which is to be considered the best way to gain confidence and respect among medical staff as well as when dealing with well-informed patients or their family members.
- Support Continuing Medical Education, Audits, Clinical incident reporting, Case discussions and Morbidity and Mortality meetings in different medical facilities.
- In case you had been encountered in an incident and called for interrogation, review the whole case beforehand and write down specific and important events and you could also refresh your memory with the patient filling and records during the interview session. Further, quote relevant literature which could strengthen your position in practical and professional matters, and lastly it is permissible to provide your testimony in writing thus to be recorded as such.
In conclusion, when you are certain that the consequences of an error are disastrous so it is of logic to be too careful. This will lead to a conclusion that the prophylactic way is by far much easier to reduce the incidence of litigations as well as providing a safe and effective method of medical practice, but this doesn't mean a defensive attitude while on the contrary means a safe and practical way based on standards of medical practice. Yet, no one is immune against pitfalls and mishaps, so let us pray to Allah to provide us with his protection and mercy and give us the strength and ability to serve our patients.
The author would like to express his deepest appreciation to Dr. Nasser M. Al-Mazroa (Director of Administrative affairs, MOH; MLC, Riyadh) and Dr. Abdelghafar A. Babker and Dr. Ismail Ibrahim Mohamed, members of the Medico-legal Committee for their kind assistance throughout the work.
| References|| |
|1.||Al-Hajjaj MS: Medical practice in Saudi Arabia, the medico-legal aspect; Saudi Medical Journal 1996; Vol.17 (1): 1-4. |
|2.||Aitkenhead AR: The pattern of litigation against anaesthetists; BJA 1994;73: 10-21. |
|3.||Eichhorn JH: Prevention of Intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 1989;70: 572-77. |
|4.||Tinker JH, Dull DL, Caplan RA, Ward RJ, Cheney FW: Role of monitoring devices in prevention of anaesthetic mishaps: a closed claim analysis. Anesthesiology 1989;71: 541-6. |
|5.||Utting JE: Pitfalls in anaesthetic practice. BJA 1987;59: 877-890. |
|6.||Sandin R, Nordstorm O: Awareness during total i.v anaesthesia. BJA 1993;71: 782-787. |
|7.||Lyons G, Macdonald R: Awareness during caesarean section. Anaesthesia 1991;46: 62-64. |
|8.||Ackers V: Wigan Health Authority. Medical Law Reports 1991;2:232-234. |
|9.||Al-Saddique AA: Medical liability, the dilemma of litigations. Saudi Medical Journal 2004; Vol 25 (7): 901-906. |
|10.||Khaddage W, Moukheiber S: Medical errors. Journal of the Arab Board of Medical Specializations 2004;6(3): 282-284. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]