BackgroundMedical malpractice is an important topic worldwide, and orthopedics is a clinical branch that is considered to be at a high risk for claims. The analysis of a series of medmal insurance claims allows forensic pathologists, clinicians, and insurance companies to probe the risk of a specific clinical branch for medical malpractice claims and highlights areas where care may be improved. We investigated the main features of a major Italian insurance broker’s archive in order to identify recurrent pitfalls in this field.Materials and methodsA retrospective study was carried out on orthopedics claims. The archive covered claims from 2002 to 2013 that targeted 1980 orthopedists.Results635 claims were found and analyzed with a focus on the clinical activity invocked in the claim, the presence of alleged team malpractice, the clinical outcome of the case, and the final forensic decision regarding the claim. 299 orthopedists had at least one malpractice claim made against them during the available period; 146 orthopedists were subject to more than one malpractice claim. Most of the claims regarded perioperative and operative cases, usually originating from civil litigation. The anatomical sites most commonly involved were the hip or knees, and sciatic nerve lesions were the main contributor.ConclusionsOrthopedics is a medical specialty with a high risk for malpractice claims. In our study, medical malpractice was observed in nearly 50% of the cases—typically in surgery-linked cases resulting in permanent impairment of the patient. Death from orthopedics malpractice seemed to be rare.Level of EvidenceIV.

In dialysis patients, both central venous catheter (CVC) insertion and CVC use during the dialysis procedure pose important legal issues, because of potentially severe, even fatal, complications. The first issue is the decision of the kind of vascular access that should be proposed to patients: an arteriovenous (AV) fistula, a graft, or a CVC. The second issue, when choosing the CVC option, is the choice of CVC: nontunneled versus tunneled. Leaving a temporary nontunneled CVC for a prolonged time increases the risk of complications and could raise a liability issue. Even when choosing a long-term tunneled CVC, nephrologists should systematically explain its potential harms, presenting them as "unsafe for long-term use" unless there is a clear contraindication to an AV native or prosthetic access. Another critical issue is the preparation of a complete, informative, and easy-to-understand consent form. The CVC insertion procedure has many aspects of legal interest, including the choice of CVC, the use of ECG monitoring, the use of ultrasound guidance for cannulation, and the use of fluoroscopy for checking the position of the metal guidewire during the procedure as well as the CVC tip before the end of the procedure. Use of insertion devices and techniques that can prevent complications should obviously be encouraged. Complications of CVC use are mainly thrombosis and infection. These are theoretically expected as pure complications (and not as malpractice effects), but legal issues might relate to inappropriate catheter care (in both the inpatient and outpatient settings) rather than to the event per se. Thus, in the individual case it is indeed very difficult to establish malpractice and liability with a catheter-related infection or thrombosis. In conclusion, we cannot avoid complications completely when using CVCs, but reducing them to a minimum and adopting safe approaches to their insertion and use will reduce legal liability.

The present study analysed the asbestos lung burden in necroscopic samples from 55 subjects free from asbestos-related diseases, collected between 2009 and 2011 in Milan, Italy. Multiple lung samples were analysed by light microscopy (asbestos bodies, AB) and EDXA-scanning electron microscopy (asbestos fibres and other inorganic fibres). Asbestos fibres were detected in 35 (63.6%) subjects, with a higher frequency for amphiboles than for chrysotile. Commercial (CA) and non-commercial amphiboles (NCA) were found in roughly similar frequencies. The estimated median value was 0.11 million fibres per gram of dry lung tissue (mf g(-1)) for all asbestos, 0.09 mf g(-1) for amphiboles. In 44 (80.0%) subjects no chrysotile fibres were detected. A negative relationship between asbestos mass-weighted fibre count and year of birth (and a corresponding positive increase with age) was observed for amphiboles [-4.15%, 95% confidence interval (CI) = -5.89 to -2.37], talc (-2.12%, 95% CI = -3.94 to -0.28), and Ti-rich fibres (-3.10%, 95% CI = -5.54 to -0.60), but not for chrysotile (-2.84%, 95% CI = -7.69 to 2.27). Residential district, birthplace, and smoking habit did not affect the lung burden of asbestos or inorganic fibres. Females showed higher burden only for amphiboles (0.12 versus 0.03 mf g(-1) in males, P = 0.07) and talc fibres (0.14 versus 0 mf g(-1) in males, P = 0.03). Chrysotile fibres were shorter and thinner than amphibole fibres and NCA fibres were thicker than CA ones. The AB prevalence was 16.4% (nine subjects) with concentrations ranging from 10 to 110 AB g(-1) dry, well below the 1000 AB g(-1) threshold for establishing occupational exposure. No AB were found in subjects younger than 30 years. Our study demonstrated detectable levels of asbestos fibres in a sample taken from the general population. The significant increase with age confirmed that amphibole fibres are the most representative of cumulative exposure.

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