Introduction

Health care entities are institutions which are and will be at risk of adverse events, due to their specifics and character. In medical terminology, an adverse event is defined as: “harm to the patient’s health caused during the diagnostic and/or treatment, not related to the natural course of the illness or the patient’s condition, and also the risk of its occurrence” [1]. A complication or a medical error may occur at every stage of patient's treatment (from the moment of admission to the hospital until the discharge). The probability of its occurrence thus may not be completely eliminated [2]. However, actions may be taken which effectively minimise its risk. Skilful and effective management of adverse event risk enables achieving a level which is not only tolerable, but also acceptable both to the medical professionals and to the society as a whole. The growing awareness of patients (both of patient rights and of the duties of health care facilities) means that the management of adverse events (including medical errors and hospital infections) becomes more and more important. The number of patient claims is growing, and as a consequence the amount of compensation (damages) paid, which may negatively impact an entity's cash flow. Learning the causes of an event, its component elements and variables which have led or may have led to its occurrence enables learning from mistakes and drawing conclusions for the future. This enables the implementation of corrective/preventive action, which should safeguard against the repeated occurrence of similar situations and possible negative repercussions [3].

The 3 selected cases of patient claims presented herein indicate not only the causes, but also describe in detail the course of an event, its medical consequences for the patient, as well as the financial consequences for the medical entity.

Materials and methods

The materials collected in this work were obtained from the Lesta law firm, specialising in, among others, medical lawsuits. The Law Office is a family company with an established position in the legal services market. He has been supporting clients since 2006. He specializes in the recovery of benefits for victims in Poland and abroad. 53 cases of claims issued by patients or patient families conducted in 2018 were subjected to analysis, of which 13 concerned hospital infections, 21 diagnostic errors, 18 therapy errors, and 1 organisational error. The specific claim amount was specified in 19 cases for a total value of PLN 3,700,000.00. (table no 1).

However due to the fact that the cases are at various stages of advancement and concern differing subject areas, it is not possible to compare them in a statistical and substantive manner. For this study, the 3 most interesting and advanced case reports were selected (from the categories of: hospital infection, diagnostic error and therapeutic error), indicating: type of event, its cause, course and consequences. Such a detailed analysis of claims enables the identification not only of the source of an error (that is, establishing the conditions and factors which have led to it), but also to undertake corrective steps and to propose preventive actions for the future.

    Case 1 — event description

The patient was admitted to the Trauma and Orthopaedic Surgery Ward for degenerative arthritis of the left hip joint in order to implant an Accolade cementless hip stem. During further treatment an inflammation of the post-operative wound has occurred, from the wound an alarm-raising strain of ESBL (+) was grown. As demonstrated in a report issued by an expert appointed for the procedure conducted by Provincial Committee Adjudicating on Medical Events — the patient did not agree to surgery, only to nursing. The agreement form in the medical documentation was not signed.

Subsequent hospital stays of the plaintiff took place in another facility, where treatment was started for the early septic loosening of endoprosthesis. After almost a year the patient was hospitalized again in the original facility, where a revision was conducted, the acetabular shell was removed and a spacer with antibiotics and antibiotic carrier was implanted. The hospital examination and the examinations performed after the hospitalization have indicated that the plaintiff has reported strong pain and being unable to move the limb in the hip due to accompanying pain resulting from the inflammation of the left hip joint after total alloplasty. As a consequence of the event a reimplantation of the acetabular shell was required. Due to the increasing negative health impacts of the medical error, the plaintiff has filed a motion with the Provincial Committee Adjudicating on Medical Events. It should be now pointed out that the Provincial Committee Adjudicating on Medical Events has deemed the event described in the motion as infection and injury caused by an incorrectly performed prosthesis implantation procedure and incorrect treatment of the plaintiff. During the proceedings of the aforementioned Committee an expert was appointed, who stated that “after the surgery and after cefazolin was given, on 31.01 Syntarpen was prescribed — an antibiotic which based on practical experience is recommended for staphylococcus infections which cause the most frequent complications in orthopaedics — the patient had fever previously. Afterwards, after obtaining initial information on the wound culture results conducted on 20.01 — G bacilli (-) ESBL (+), on 21.01 — the doctor has prescribed Doxycycline 2x100 mg iv to the patient, to which the microorganism was susceptible according to the in vitro antibiogram, but which is not recommended for the treatment of infections caused by Enterobacter cloacae ESBL (+), which is classified as an alarm-raising pathogen. The date of prescribing the aforementioned antibiotics assessed based on entries in doctor’s observations are different than the dates entered in the Hospital Infection Control Sheet — Syntarpen 19-25.01, Doxycycline — 25.01. The presented documentation also contains a hospital infection sheet, in which the patient was classified with a “hospital wound infection” — date of symptom occurrence 16.01. — which confirms the occurrence of a hospital infection of the patient.” Moreover, in a supplementary opinion, an expert appointed for the procedure of the Provincial Committee Adjudicating on Medical Events has clearly indicated that the hospital infection was already noticed during the hospitalization.

As demonstrated by the decision of the Provincial Committee Adjudicating on Medical Events, it is undeniable that the plaintiff was infected by a biological disease agent, and moreover a personal injury has undoubtedly occurred in the form of physical and psychological pain caused by treatment and rehabilitation.

The requested compensation amount totalling PLN 90,000.00 is justified by the claimant's attorney by the fact that the plaintiff still bears significant negative health impacts resulting from incorrect treatment at the defendant institution. It should be pointed out that the fault of medical personnel remains beyond doubt. The other conditions for compensatory liability, e.g. the fact that the plaintiff was injured and the causal link between the claim and the injury were sufficiently demonstrated during the procedure conducted by the Provincial Committee Adjudicating on Medical Events.

Case 2 — event description

The injured party, age 40, was admitted to a hospital to the Trauma and Orthopaedic Surgery Ward due to the pain of the right knee joint, suspected medial meniscus tear. In the hospital the patient underwent an arthroscopic right knee surgery, during which injury was caused by burning the rear surface of the left thigh. For unclear reasons the history of illnesses from the hospital stay does not contain any remark on an adverse event in the form of a burn to the patient's body. This is an oversight or a wilful act that should result in a special explanatory proceedings and in disciplinary and professional sanctions.
In the medical history report we can read as follows: “Patient admitted to the hospital with pain of the right knee joint and suspected medial meniscus tear. Surgical treatment — joint arthroscopy, the course of the treatment and hospitalization without complications, discharge to home with recommendations”.

However, the burn to the patient, which is a fact that was concealed, was the cause of significant pain and discomfort preventing the return to normal life after the knee arthroscopy. Due to a non-healing, extensive post-burn wound the patient visited a General Surgery Clinic, and then to a hospital, based on a referral issued by the clinic.  He was admitted urgently to a General Surgery Ward with a diagnosis of: „Lower limb ulceration, not classified elsewhere”. The victim was diagnosed with skin necrosis on the rear of the left thigh. The necrosis was described as black skin with an inflammatory infiltration, oval-shaped, with dimensions of 7 x 4 cm. During the first day of hospital stay, the victim underwent surgery, during which the necrosis was excised. The patient was discharged with a referral for out-patient treatment with sick leave for 14 days. The patient spent a total of 5 months on sick leave, of which 1,5 months was attributed solely to the burn.

The patient has regularly visited the General Surgery Clinic, during which the necrotic parts of the wound were removed. The wound did not heal, and an additional chafed area has appeared around it, also difficult to heal.

The requested compensation amount totalling PLN 85,000.00 is justified by the claimant's attorney by the fact that the injury suffered by the victim is permanent, and its effect is not only visual, but also causes significant discomfort in his daily existence. Moreover the injury has caused physical suffering to the victim, who in relation to the burn was required to undergo long-term, painful treatment, which significantly hindered his normal professional, family and matrimonial life. The placement of the burn has clearly restricted normal sitting and sleeping and practically prevented driving a car, which meant that the victim was dependent on public transport and on third parties. The patient has suffered insomnia caused by the itching and burning of the wound for many months after the event. The victim also experienced psychological suffering. Additional pain suffered during the surgery has caused him significant stress. The injury had also an impact on the situation of the entire family — additional care taking duties and most of housekeeping was performed mainly by the claimant's wife.

The collected documentation of the injury and the presented arguments fully justify the claim for compensation. The verdict of the Appellate Court in Katowice of 21 November 2007 (IACa 617/07, Prawo i Medycyna 2011 no 1) should be quoted here. The first argument stated: “In order to establish the amount of compensation for the injury suffered it is important not only to consider the degree of previous suffering of the injured, but also a forecast for the future.” In this case it is certain that the scar will be healing for more than a dozen months and will leave permanent marks on the victim's body and psyche. Whereas the second argument of the quoted verdict also applies due to the behaviour of personnel, who probably tried to hide the caused injury and has not noted the event in the medical documentation, which is an outrageous behaviour. This argument states: “The behaviour of doctors after the procedure which has caused the injury may also impact the moral damages caused. Lack of effort to counteract the negative effects may be treated as an additional injury subject to compensation.”

Case 3 — event description

Patient has contacted her GP due to chest pains and shortness of breath. The patient was diagnosed with arterial hypertension and tests were ordered. Persistent symptoms have resulted in the patient being referred to a hospital, in order to diagnose a possible heart disease. On the next day the patient has presented herself to a hospital and was admitted to a general practice ward with a cardiological profile with an initial diagnosis of stenocardia and arterial hypertension. After the preliminary steps the admitting doctor has ordered a series of necessary laboratory tests, as well as ECG and abdominal ultrasound exam, also prescribing medication. However, the medical documentation has no results of the ordered tests — which indicates that they were not conducted. On the next day of the patient's stay in the hospital, she was subjected to exercise electrocardiogram, which was interrupted in the third minute due to chest pain. During this test the submaximal pulse was not reached, and in the medical documentation the exercise test was marked as non-diagnostic. On the same day an ECG was performed, the result of which clearly differed from the one made by the GP. The patient complained of chest pains. Despite that the medical personnel did not continue further cardiological diagnostics, and it was deemed that the cause of the reported ailments was a gallbladder stone — which resulted in a cholecystectomy procedure being conducted. During the first days after the operation the patient's condition was generally good, although she complained of stomach aches. In subsequent days due to an tonsilitis and laryngitis the patient underwent a laryngologic consult. After the consult the patient received Amoksiklav antibiotic intravenously. Soon afterwards the patient presented with significant chest pain combined with a drop of pressure, sudden shortness of breath, fluctuating consciousness and symptoms of massive pulmonary embolism. Reanimation was commenced on the post-operative care ward, with oxygen and drugs. The condition of the patient improved, but a circulatory failure occurred after a few dozen minutes. Reanimation was commenced again — with no results. The patient died. The ECG record and the post-mortem examination indicated an extensive anterior wall myocardial infarction as the cause of death.

The Regional Prosecutor has brought indictments against three doctors who were members of medical personnel, charging them with failure to exercise due diligence during the care of the patient, which brought a direct risk of the loss of life and as a consequence led to her death. The court procedures intended to establish the criminal liability of the doctors took more than 6 years. One of the doctors who took party in the treatment was convicted as guilty of violating article 4 of the Medical Profession Act and article 8 of the Code of Medical Ethics by not exercising due care in the process od diagnosing and treating (abandoning the testing of cardiac markers — CK-MB, troponin; abandoning the performance of ECG examinations while simultaneously considering the exercise ECG to be non-diagnostic, which in effect has resulted in the incorrect diagnosis of the primary illness, and as a result qualifying the patient for the cystocholectomy). The experts appointed during the criminal proceedings have unequivocally stated that the patient's cause of death was acute respiratory and circulatory failure during a myocardial infarction. They also established that the medial procedure at the Internal Ward of the hospital was incorrect and medical errors were made, both related to diagnostics (undiagnosed myocardial ischaemia) and decisions (transferring the patient to a surgery ward in order to conduct a cholecystectomy). The opinion of the experts was not discredited by the accused, and as a credible impersonal evidence became the basis for the factual findings and for the verdict.

The requested compensation amount totalling PLN 240,000.00 is justified by the claimant's attorney by the incorrect diagnostic process, which resulted in the doctor making an erroneous decision to transfer the patient to the surgical ward in order to perform a surgery. Appropriate diagnosis of the patient would give her a chance at being fully cured, and would certainly prevent her death, as confirmed both by experts and by the court. The plaintiffs were also very bitter because of the doctors’ attitude, since they never admitted their errors and did not apologize for them.

As a consequence it was decided that the hospital is responsible for the results of the event, pursuant to article 430 of the Civil Code in reference to article 415 of the Civil Code.

Discussion

The increasing number of claims for medical errors and of the resulting compensations being paid, as well as the significant premiums for the insurance for this events result in an increasing interest the aforementioned subject. Moreover, the number of complaints being examined in Poland is higher than the European average and increases annually by 10 to 30% (average by 14%). In 2017 their number increased by almost 45% compared to the previous year [4]. The newest statistics of the Ministry of Justice indicate that the courts are assigning increasing amounts. In the years 2014–2017 the amount of compensation and damages increased by a total of 70 percent. In the 2017 financial compensation for damages caused in the national health care system were received by 81 persons for a total amount of PLN 13.5 million (in 2014 it was less than PLN 8 million). In 2017 the private hospitals were also required by courts to pay PLN 56 thousand in damages and over 700 thousand in compensation (30% more than in 2016). The lawyers specialising in such matters admit that the amounts increase only in the most severe cases, related to significant impairments to health. In other cases they remain at a constant level and do not exceed PLN 100 thousand [5].

The median overall incidence of in-hospital adverse events was 9.2%, with a median percentage of preventability of 43.5%. More than half (56.3%) of patients experienced no or minor disability, whereas 7.4% of events were lethal. Operation- (39.6%) and medication-related (15.1%) events constituted the majority [6].

The most common causes of medical claims include: not performing or restricting access to medical services (not ordering a test, premature discharge), incorrect diagnosis, difficulties with obtaining medical documentation and lack of correct doctor-patient communication (e.g. providing information on health in a manner that is incomprehensible) [7].

The increasing awareness of patients and their families is also very significant. They are becoming increasingly familiar with the legal regulations in force, and when they feel they have been mistreated and have suffered a loss they know how and when to effectively seek their rights.

The resources of the given medical entity, including: personnel (its qualifications, experience, competences, physical and mental shape), state of the art and working medical equipment, or rooms which meet appropriate sanitary and epidemiological standards and requirements have a significant impact on the risk of occurrence of adverse events. Old, defective equipment, overworked medical personnel, not obeying procedures and standards may significantly increase this risk, causing a worsening of the patient's health, additional complications, harm to the patients` health, and as a consequence claims by the patient [8]. 
In The Lancet we read: “Inadequate sleep leads to inadequate health care. Junior doctors working a 34 h shift will make 460% more diagnostic mistakes than when well rested. These same tired physicians will commit 36% more serious medical errors than those working 16 h or less. Seasoned physicians can suffer the same compromise of medical skills. A senior attending surgeon who has slept only 6 h or less the previous night is 170% more likely to inflict a serious surgical error on a patient, relative to when he or she has slept adequately” [9].

Summary

In Poland there is no dedicated system for collecting comprehensive information on patient claims. There are no reliable and credible statistics, which significantly hinders risk management. Despite the fact that hospitals are increasingly equipped with applications used to report adverse event, the number of injuries or deaths caused by medical malpractice is estimated usually based on assumptions only (there is a lack of interest and of use of the aforementioned tool by medical personnel).

The available publications indicate that medical errors occur every tenth hospitalization. This means that approx. 830 thousand medical errors are made annually.
Of the 500 complaints analysed by Adam Sandauer from the Primum Non Nocere Patients Association approximately 80% were considered to be valid after preliminary analysis. Approx. 33% of them were childbirth related, approx. 25% concerned hospital infections, and a significant majority of the remaining cases were operational errors (items left in the body during surgery) and erroneous diagnoses. A substantial part of these events are preventable. Since a large proportion of the in-hospital events are operation- or drug-related, interventions aimed at preventing these events have the potential to make a substantial difference [6].

Corresponding author: Marczak Michał, Division of Quality Services, Procedures and Medical Standards, Medical University of Lodz, Lodz, Poland; Gen. J. Haller Pl 1, 90‑647 Łódź; michal.j.marczak@gmail.com

Conflict of interest: none

Source of funding: none

Charts and figures

Table no 1. Lawsuits conducted in 2018 concerning adverse events in the health care system — own material