Abstract
Purpose
Meningitis is a potential complication in otolaryngologic procedures and conditions. Severe sequelae make understanding factors involved in relevant malpractice litigation critical. We analyze pertinent litigation for awards, outcomes, patient demographic factors, and other alleged causes of malpractice.
Methods
Pertinent jury verdict and settlement reports were examined using the Westlaw legal database (Thomson Reuters, New York, NY).
Results
Twenty-three cases (60.5%) involved non-iatrogenic injuries, including inadequate treatment or failure to diagnose sinusitis or otitis media, while 15 (39.5%) involved iatrogenic cases, mostly rhinologic procedures. 36.8% of cases were resolved for the defendant, 28.9% with juries awarding damages, and 34.2% with settlements. Although not statistically significant, mean damages awarded were higher than settlements ($2.1 vs. 1.5M, p = 0.056), and cases involving pediatric patients were more likely to be resolved with payment than those with adult litigants (80.0% vs. 52.2%, p = 0.08 respectively). Other frequent alleged factors included permanent deficits (63.2%), requiring additional surgery (41.1%), death (34.2%), cognitive deficits (21.2%), deafness (15.8%), and inadequate informed consent (33.0% of iatrogenic cases).
Conclusions
Practitioners facing litigation related to meningitis may wish to consider these findings, notably for cases involving death or permanent functional deficits, as cases with out of court settlements tended to be resolved with lower payments. Cases involving misdiagnosis may be more likely to be resolved with payment compared with iatrogenic cases. By understanding the issues detailed in this analysis and including them in the informed consent process for patients undergoing rhinologic and otologic procedures, otolaryngologists may potentially improve patient safety and decrease liability.
1
Introduction
Meningitis is a feared complication of many otolaryngologic diseases and procedures. Due to the close proximity of the paranasal sinuses and the middle ear structures to the brain, intracranial complications of sinusitis and otitis media are not uncommon. Hence, it has been reported that intracranial complications occur in 3.7% of patients admitted for pansinusitis, and over 3% of cases of meningitis may be associated with otitis media .
Procedural complications may also lead to iatrogenic meningitis. Endoscopic sinus surgery (ESS) is particularly vulnerable to intracranial complications, as much of the surgery takes place around the skull base. A recent analysis reported that meningitis accounts for greater than 10% of complications in ESS .
Prior medicolegal analyses have examined malpractice litigation regarding a variety of procedures of interest to practicing otolaryngologists . However, to the best of our knowledge, there has been no analysis examining the scope and impact of meningitis on malpractice litigation in any specialty. In this study, we characterize the effect of this potentially severe complication as it relates to otolaryngologic procedures and conditions, as a greater understanding of the factors critical to initiating litigation and determining legal responsibility may be useful for minimizing physician liability and associated costs, and improving patient care.
2
Materials and methods
The Westlaw legal database (Thomson Reuters, New York, NY) was searched for litigation regarding meningitis related to otolaryngologic procedures and conditions ( Fig. 1 ). This computerized resource covering publically available federal and state court records has previously been valuable in medicolegal analyses on a variety of topics . While court record collection patterns may vary by jurisdiction, as numerous commercial vendors provide these data to Westlaw, this resource contains both attorney-submitted cases from all jurisdictions as well as non-voluntarily submitted cases from many jurisdictions , the latter of which may contain legal parties labeled with terms such as “confidential,” “john/jane/jack doe,” and “anonymous.” Although numerous out of court settlements may not progress to the point of inclusion in publically available court records, this resource has still proven valuable for analysis of factors raised in litigation.
Thirty-eight jury verdict and settlement reports were ultimately included for analysis. Patient demographic information, defendant specialty, outcome and awards, and other alleged causes of malpractice were recorded from these reports. Data collection was completed in April 2013.
2.1
Statistical analysis
Mann–Whitney U-tests and Pearson’s Chi Square were used for comparison of continuous and categorical variables respectively, with threshold for significance set at p < 0.05. For statistical calculation, SPSS version 20 (an IBM Company, Chicago, IL) was used.
2
Materials and methods
The Westlaw legal database (Thomson Reuters, New York, NY) was searched for litigation regarding meningitis related to otolaryngologic procedures and conditions ( Fig. 1 ). This computerized resource covering publically available federal and state court records has previously been valuable in medicolegal analyses on a variety of topics . While court record collection patterns may vary by jurisdiction, as numerous commercial vendors provide these data to Westlaw, this resource contains both attorney-submitted cases from all jurisdictions as well as non-voluntarily submitted cases from many jurisdictions , the latter of which may contain legal parties labeled with terms such as “confidential,” “john/jane/jack doe,” and “anonymous.” Although numerous out of court settlements may not progress to the point of inclusion in publically available court records, this resource has still proven valuable for analysis of factors raised in litigation.
Thirty-eight jury verdict and settlement reports were ultimately included for analysis. Patient demographic information, defendant specialty, outcome and awards, and other alleged causes of malpractice were recorded from these reports. Data collection was completed in April 2013.
2.1
Statistical analysis
Mann–Whitney U-tests and Pearson’s Chi Square were used for comparison of continuous and categorical variables respectively, with threshold for significance set at p < 0.05. For statistical calculation, SPSS version 20 (an IBM Company, Chicago, IL) was used.
3
Results
Out of the 38 jury verdict and settlement reports included in this analysis, 23 (60.5%) were related to non-iatrogenic cases and 15 (39.5%) were related to iatrogenic injury from operative management ( Fig. 1 ). Cases were resolved in the defendant’s favor 36.8% of the time, with damages awarded by juries in 28.9% and out of court settlements in 34.2% ( Fig. 2 ). In cases resolved with payment, the average payment was $2.1M±$434,671 Standard Error of Mean (SEM); damages awarded by juries were higher than out of court settlements ($2.7M vs. $1.5M), a result that bordered statistical significance (p = 0.056) ( Fig. 2 ). Nearly half of cases involving iatrogenic injury were resolved in the defendant’s favor versus 1/3 of non-iatrogenic cases, although this comparison did not reach statistical significance (p = 0.42) ( Fig. 2 ). Seven of 20 (35.0%) rhinologic cases (including both surgical and non-surgical litigation) and 7 of 17 (41.1%) of otologic cases were resolved in the defendant’s favor ( Fig. 2 ).
Cases involving pediatric patients were resolved in the defendants favor less frequently (20.0%) than those involving adults (47.8%), a result that bordered statistical significance (p = 0.08) ( Fig. 3 ). Despite the greater success of pediatric litigants, no statistical difference was noted upon comparison of payments with those of adult litigants (p = 0.98) ( Fig. 3 ).
The alleged failure to diagnose meningitis (both in iatrogenic and non-iatrogenic cases) in a timely manner was the most common factor noted in this analysis (84.2%), followed by sustaining a permanent deficit (63.2%), requiring additional surgery as a result of a complication (41.1%), and death (34.2%) ( Table 1 ). Inadequate informed consent was noted in 33.0% of iatrogenic cases. Otolaryngologists were the most commonly named defendants ( Table 2 ), followed by emergency medicine physicians and pediatricians. The specific factors in cases resolved with payments are detailed in Table 3 . Ohio was the most common jurisdiction noted in this analysis ( Table 4 ).
| % of Cases | |
|---|---|
| Untimely Dx | 84.2% |
| Permanent Deficit | 63.2% |
| Additional Surg. | 42.1% |
| Death | 34.2% |
| Skull Base | 31.6% |
| Cognitive | 21.2% |
| Employment | 18.4% |
| CSF Leak | 18.4% |
| Consortium | 15.8% |
| Hearing | 15.8% |
| Informed Consent | 13.2% |
| Unnecessary | 10.5% |
| Visual | 10.5% |
| Anosmia | 10.5% |
| CVA | 7.9% |
| CN Injury | 7.9% |
| Dysgeusia | 5.3% |
| Seizures | 2.6% |
| % of Cases | |
|---|---|
| Otolaryngology | 44.7% |
| Emergency Med. | 21.0% |
| Pediatrics | 21.0% |
| Family Medicine | 7.9% |
| Internal Medicine | 7.9% |
| Neurosurgery | 5.3% |
| Neurology | 5.3% |
| Resident Physician | 5.3% |
| A/G | Award (P/S) | Def | Iat | FtDx | IC | Surg | Unn. | Perm | Death | P/C |
|---|---|---|---|---|---|---|---|---|---|---|
| < 1M | 2.1M (P) | ER | N | N | N | N | N | N | Y | OM |
| < 1F | 1.1M (P) | ER | N | Y | N | N | N | N | Y | OM |
| < 1F | 600K (P) | Ped | N | Y | N | Y | N | N | Y | OM |
| < 1F* | 1.6M (P) | Ped | N | Y | N | N | N | Y | N | OM |
| < 1F* | 3.0M (P) | Ped | N | Y | N | N | N | Y | N | OM |
| 6M | 8.5M (P) | Ped | N | Y | N | N | N | N | Y | Sns |
| 31M | 3.8M (P) | ENT/FM | N | Y | N | N | N | N | Y | OM |
| 38M | 4.7M (P) | ENT | N | Y | N | Y | N | N | Y | Sns |
| 42M^~ | 300K (P) | ENT | Y | Y | N | Y | N | Y | N | ESS |
| M*` | 2.5M (P) | ENT | Y | Y | N | N | N | Y | N | ESS |
| F*` | 1.5M (P) | ENT/NS/N | Y | Y | Y | N | Y | Y | N | ACN |
| 1F* | 3.0M (S) | Ped | N | Y | N | N | N | Y | N | Ton |
| 10F¿ | 1.0M (S) | FM | N | Y | N | N | N | Y | N | OM |
| 11M | 650K (S) | ER | N | Y | N | N | N | N | N | Sns |
| 12M | 360K (S) | Ped | N | Y | N | N | N | N | Y | Sns |
| 16F() | (S) | ER/N | N | Y | N | Y | N | Y | N | Sns |
| 17F*(b) | 1.0M (S) | Ped | N | Y | N | N | N | Y | N | Sns |
| 25M(b) | 4.8M (S) | ER | N | Y | N | Y | N | Y | N | OM |
| 32F | 2.5M (S) | ER | N | Y | N | Y | N | N | Y | OM |
| 32M ~ | 625K (S) | ENT | Y | Y | N | Y | N | Y | N | ESS |
| 35F ~ | 1M (S) | ENT | Y | N | N | Y | Y | Y | N | Sep |
| 51M ~ | 2.6M (S) | ENT | Y | N | N | Y | N | Y | N | ESS |
| 57M^ | 575K (S) | ENT | Y | N | N | Y | N | Y | N | ESS |
| F | 99K(S) | ENT | Y | Y | N | N | N | N | Y | ESS |
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