Medico-legal risk: What physicians involved in gynecology surgery need to know

As of the end of 2022, 1,722 CMPA members were obstetricians and gynecologists (Type of Work 93), and 285 were gynecology surgeons (TOW 84). In addition, some general surgeons, urologists, plastic surgeons, and anesthesiologists may have been potentially involved in gynecological surgeries that were not related to labor and delivery.

These graphs depict findings drawn from the 350 civil legal cases, College complaints, and hospital matters involving gynecological surgery that were closed by the CMPA between 2016 and 2020. They are provided here to help you understand your medico-legal risk, and they are accompanied by key learning resources that will help you mitigate that risk level.

What are the most common patient complaints? (n=350)

Complaints are a reflection of the patient’s perception that a problem occurred during care. There may be more than one complaint per case. These complaints are not always supported by peer expert ¹ opinion. Peer experts may not be critical of the care provided, or may have criticisms that are not part of the patient allegation.

CMPA LEARNING

Our learning resources can help you develop best practices relevant to your work in gynecological surgery:

• CMPA Workshop: Theatre Arts
• "Informed consent", CMPA Good practices
• "Patient-centered communication", CMPA Good practices

What are the most frequent interventions with peer expert criticism? (n=350)

Intervention frequencies among medico-legal cases are likely representative of physicians’ practice patterns and do not necessarily reflect high-risk interventions.

Patient injuries often observed in these procedures include accidental puncture and perforation to the bladder or intestines, and injuries to the ureters or blood vessels.

The most common peer expert criticisms on these interventions include:

• Deficient patient assessment
• Inadequate informed consent process
• Failure to perform a diagnostic test or intervention
• Deviation from a clinical protocol or procedure
• Inadequate documentation

What are the top factors associated with severe patient harm? ² (n=350)

The following risk management considerations have been identified for physicians involved in gynecology surgeries:

CMPA Learning

• Working in an environment with limited resources (November 2022)

Risk reduction reminders

The following risk management considerations have been identified for physicians involved in gynecology surgeries.

Pre-operative

• Ensure all diagnostic indices have been considered including a thorough differential diagnosis. Consider risk factors from the patient’s medical history, co-morbid conditions, and current medications and their impact on the patient treatment.
• Ensure the consent discussion includes clear and accurate explanations of the risks and benefits of the proposed procedure or therapy and post-operative expectations, as well as alternative options. Check for patient and family understanding, and answer questions. Tailor the discussion to the patient’s level of health literacy, and provide sufficient time to address any patient questions. Document the discussion details in the medical record.

Intra-operative

• Appropriately advocate on behalf of patients to solve issues that arise when limited resources pose an impediment to safe patient care, and document any steps you have taken to attempt to resolve the resource issue within a reasonable timeframe.
• Confirm that equipment has been appropriately tested, and is available and in working order.
• Consider the risks of intra-operative injuries during the procedure, and protect vital structures to mitigate this risk. In a timely manner, document details of action taken to protect vital organs or structures, including surgical techniques, anatomical findings, and variants in the operative note, as well as any difficulties encountered and actions taken to address the issue.

Post-operative

• Ensure appropriate post-operative patient monitoring has been ordered. Ask team members (e.g. nurses, residents) to alert you of unexpected signs and symptoms.
• Have a reliable system in place to facilitate the timely receipt, effective review, and appropriate management and follow-up of diagnostic tests.
• Ensure the patient’s post-operative condition is carefully documented. In the event of a complication, ensure it is disclosed to the patient and family in a timely manner, and that the discussion is documented in the medical record.

Questions?

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Notes

1. 1. 
   Peer experts refer to physicians who interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided. They are typically of similar training and experience as the physicians whose care they are reviewing.
2. 2. 
   Severe patient harm refers to harm that results in patient death or severe outcome.
3. 3. 
   Patient factors include any characteristics or medical conditions that apply to the patient at the time of the medical encounter, or any events that occur during the medical encounter.
4. 4. 
   The American Society of Anesthesiologists (ASA) Physical Status Classification System is used by physicians to predict a patient’s risks ahead of surgery. ASA status 3 indicates severe systemic disease.
5. 5. 
   Based on peer expert opinions.