WSOA Closed Claims Project – Upper Extremity Claims

Main Data Collection Form (August 13, 2010)

Section 1.PatientDemographic Characteristics

Pages 1 & 2 are completed by support staff

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WSOA Closed Claims Project – Upper Extremity Claims

Main Data Collection Form (August 13, 2010)

1.1Year of Event______

1.2Sex:

0Female

1Male

1.3Age:_____years(or)_____mos.

1.4Weight:_____lbs (or)_____kg

1.5Height:_____inches(or)_____cm

1.6Obese? (BMI > 30)

1Yes

0No

77Unknown

1.7Patient’s primary insurance:

0None

1Private / Commercial

2Medicaid

3Medicare

4Workman’s Compensation

77Unknown

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Section 2.Patient’s Health Status& Other Presenting Characteristics

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2.1ASA Physical Status (check one):

1P1, A normal healthy patient

2P2, A patient with mild systemic disease

3P3, A patient with severe systemic disease

4P4, A patient with severe systemic disease that is a constant threat to life

5P5, A moribund patient who is not expected to survive without the operation

77Unknown

If ASA status is not in the records, would you

describe this patient as more likely an:

1ASA 1-2 (relatively healthy)

2ASA 3-5 (some serious health issues)

2.2Co-morbid Conditions (check all that apply):

1Coronary Artery Disease (CAD)

1CHF (recent)

1COPD or respiratory insufficiency

1Diabetes mellitus

1Myocardial infarction in past 6 months

1Hypertension

1ETOH more than 2 drinks per day

1Smoking within past year

1Other substance abuse
(specify)______

1Other relevant co-morbidity:
(specify)______

2.3Emergency procedure?

1Yes

0No

77Unknown

2.4Claim began with ER coverage?

1Yes – orthopedic care began in the ER

0No – orthopedic care began later or ER not an issue in this claim

7 Unknown

Presenting complaint ___________

______

2.5Etiology of presenting complaint

1Traumatic injury

2Degenerative, chronic, overuse, disease

7 Unknown

2.6Presenting site of problem______

1 Right2Left 7 Unknown side of body

2.7Anatomical description:

1 Bones2 Nerves

3 Joints5 Spine

6 Skin8 Multiple

4 Tendons, muscle, bursa

9 Other (specify) ______

77 Unknown

2.8Primary planned procedure:
______

2.9If the procedure was changed, what procedure was actually done?

2.10Procedure scheduled as…

1Inpatient

2Outpatient

77Unknown

Check type of facility

1Hospital or ambulatory surgery center

2Office or clinic

77 Unknown

2.11Surgical Position:

1Supine 2 Lateral

3Sitting or beach chair 4 Prone

8Other: ______

9Unknown

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Section 3. Legal Action

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3.1Was a lawsuit filed?

1Yes

0No

3.2Defendants(check all that apply):

1Primary surgeon
(specialty)______

1Second surgeon
(specialty)______

1Call partners

1Surgery resident (specify year)______

1Hospital staff (nurses, technicians)

1Radiologist / radiology staff

1Anesthesia staff

1ER physicians / staff

1Primary care physician
(specialty)______

1Others
(specify)______

3.3Attending surgeon status:

1Private practice

2Employed by hospital

3Academic practice

77Unknown

3.4How was the claim resolved?

1Settlement

2Judgment (dismissed, summary judgment, or jury verdict) by court

3Dropped/ discontinuedby patient / plaintiff

3.5Year of payment (or year claim closed):

______

3.6Payments made by specified defendants, excluding legal costs

Amount$0Unknown

Primary surgeon..$______0-1

Other surgeon....$______0-1

Anesthesia...... $______0-1

Hospital...... $______0-1

Others...... $______0-1

Total...... $______0-1

ALAE...... $______0-1

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Section 4. Documentation

4.1Were the medical records available for review for this claim?

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1Yes

1No

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Section 5.Surgical Characteristics

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5.1Wound class:

1Clean

2Clean/Contaminated

3Contaminated

4Dirty/Infected

5.2Primary anesthetic:

0None

5Local only

1General anesthesia only

2Regional (+/- local infiltration)

3General anesthesia plus regional

4Monitored anesthesia care (MAC)

7Unknown

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Section 6.EVENTS - Clinical care issues which lead to the claim or caused injury to the patient

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check all events that were important issues in this claim.

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Diagnosis related events

1Delayed diagnosis

1Failure to diagnose
(specify) ______

1Failure to perform diagnostic tests
(specify) ______

1Misinterpreted diagnostic tests

1Performed unnecessary diagnostic tests

1Misdiagnosis
(specify) ______

1Other diagnostic issue:
(specify)______

Treatment related events

1Delayed treatment
(etiology) ______

1Failure to treat

1Unnecessary surgery

1Wrong treatment/surgical procedure

1Wrong side, limbor digit

1Wrong patient

1Retained foreign body

1Technical misadventure during surgery
(specify)______

1Other treatment issue:
(specify)______

Medication related events

1Wrong drug (specify) ______

1Wrong dose (specify)______

1Timing of antibiotic
(specify) ______

1Adverse/allergic drug reaction______

1Other medication issue(specify)______

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Equipmentrelated events

1Equipment failure
(specify)______

1Wrong implant

1Implant failure or malfunction

1Improper positioning of implant

1Improper fixation of implant

1Misplacement of suture anchors

1Mechanical injury from scope or instrument
(specify)______

1Peripheral IV problem

1Anesthesia equipment problem
(specify)______

1Other equipment issue (specify) ______

______

Miscellaneous damaging events

1Patient moved during procedure

1Patient dropped or fell

1Pressure, positioning, padding problem

1Uncontrollable bleeding

1Transfusion-related event (specify) ______

1Anesthesia event

1Other event
(specify)______

1Patient condition (specify) ______

1No damaging event occurred

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Primary damaging event

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6.1If you have checked more than one damaging event, list the primary event here:

______

6.2If no event occurred, what precipitated the claim?

______

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OPINION ONLOCATION OF EVENT/INJURY

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6.3Where did the damaging event probably occur?

0Emergency Room6Ward/floor

1Pre-incision7Post discharge

2Intra-procedure8Impossible to

3In transitjudge

4PACU98Other (specify)

5ICU

6.4Where did the injury become apparent?

0Emergency Room6Ward/floor

1Pre-incision7Post discharge

2Intra-procedure8Impossible to

3In transitjudge

4PACU98Other (specify)

5ICU

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Section 7.Pre- and Post-treatment Assessment of Functional Status at Complaint Site

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7.1Pre-treatment function level at presenting site:

3 Full range of motion

2 Partial range of motion

1 Almost no range of motion

7.2Did the patient report any of the following at the presenting site? (If yes, describe.)

1Pain ______

1Instability ______

1Loss of functionality ______

1Weakness ______

1Stiffness ______

1Crepitus ______

1Loss/change in sensation______

Post-treatment status

7.3Post-treatment were each of the following better, worse, or about the same at the presenting site?

Better About the same Worse (specify) No information

Pain3 2 1 77

Instability3 2 1 77

Functionality3______ 2 1 77

Weakness3 2 1 77

Stiffness3 2 1 77

Crepitus3 2 1 77

Sensation3 2 1 77

Range of motion3 2 1 77

7.4Post-treatment did the patient report any of the following problems at a new site? (If yes, specify site and describe new problem.)

1Pain ______

1Instability ______

1Loss of functionality ______

1Weakness ______

1Stiffness ______

1Crepitus ______

1Loss/change in sensation ______

1Loss of range of motion ______

Section 8. Complications: Claimed physical / psychological injury, loss, negative outcome

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Brain Damage

8.1Brain damage?

1Yes

0No

77Unknown

Tissues and Other Organ Injury

8.2Surgical laceration/contusion of:

1Artery (specify)______

1Vein (specify)______

1Nerve (specify)______

1Tendon (specify)______

1Other laceration or contusion
(specify site)______

8.3New fracture?

1Yes, (specify site)______

8.4Non- union of fracture?

1Yes

8.5Mal- union of fracture?

1Yes

8.6Skin injury:

1Scar/disfigurement

1Burn (thermal)

1Skin reaction (inflammatory, pressure)

8.7Other organ damage:

1Amputation (specify) ______

1RSD/CRPS (specify) ______

1Compartment syndrome

1Sepsis/infection (non-surgical site)

1Surgical site/wound infection

1Wound healing problem (non-infective)

1Wound pain (chronic)

1Tendon rupture (specify)______

1Muscle damage (specify)______

1Other organ damage complication
(specify)______

RespiratoryAirwayComplications

8.8Did a respiratory arrest occur?

1Yes

0No

77Unknown

If yes, was it appropriately treated?

1Yes

0No

77 Unknown

8.9Respiratory complications:

1PE (Pulmonary embolus)

1Postoperative pneumonia (not aspiration)

1Pneumothorax

1Pulmonary edema

1Respiratory distress syndrome (ARDS)

1Other respiratory complication
(specify)______

Nerve Damage

8.101Nerve damage (check all that apply):

1Median

1Ulnar

1Radial

1Brachial Plexus

1Musculotaneous

1Axillary

1Spinal cord:

1Cervical

1Other location: ______

1Other nerve(s): ______

8.11Anatomic level of nerve injury:

1Above Clavicle 2 Clavicle to axilla

3Upper Arm 4 Elbow

5Forearm 6 Wrist

7Hand 8 Finger

5Unknown

8.12Cause of nerve injury:

1Probably positional

2Possibly positional

3Block related

4Surgery (elaborate in narrative)

5Tourniquet

6Pre-existing nerve damage

7No clear evidence of injury

8Other cause(specify)______

9Unclear mechanism/insufficient data

8.13Was extra padding applied to the affected extremity?

1Yes

0No

77 Unknown

8.14Bilateral nerve damage?

1Yes

2No

Cardiovascular Complications

8.15Did a cardiac arrest occur?

1Yes

0No

77Unknown

If yes, was it appropriately treated?

1Yes

0No

77 Unknown

8.16Cardiovascular complications:

1CHF (Congestive Heart Failure)

1DVT (Deep Vein Thrombosis)

1Myocardial infarction

1Stroke

1Other cardiovascular complication
(specify) ______

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Other Complaints in Claim

8.17Other complaints:

1Dissatisfaction with surgical outcome, (e.g., range of motion, function, stability, pain)

1Emotional distress/ fright

1Prolonged hospital stay

1Prolonged recovery

1Surgery cancelled or not completed

1Unplanned ICU stay

1Unplanned re-admission

1Unplanned re-operation

1Unscheduled admission of outpatient

1Other complaint about surgical care

(specify) ______

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Section 9.Severity of Injury For Patient

9.1Please code the severity of injury for the patient.

0No obvious injury

1Emotional only (fright, awake, pain during anesthetic)

Temporary

2Insignificant (lacerations, contusions, no delay in recovery)

3Minor (fall in hospital, recovery delayed- extra time in recovery room or hospital)

4Major (brain damage, nerve damage, unable to work, prolonged hospitalization)

Permanent

5Minor (damage to organs, non-disabling injuries)

6Significant (loss of eye, deafness, loss of one kidney or lung)

7Major (paraplegia, loss of use of limb, blindness, brain damage)

8Grave (severe brain damage, quadriplegia, lifelong care or fatal prognosis)

9Death

9.2If the patient died, was an autopsy performed?

1Yes

0No

If autopsy was performed, was it useful or harmful to the orthopedic physician’s defense?

1Useful

2Harmful

3Neither useful nor harmful

77Impossible to determine/Unknown

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Section 10.Reviewer’s Professional Opinion

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10.1Rate the contribution of the following to the patient’s injury:

TotallyImpossible

NoneMinorMajorresponsibleto judge

Surgery01237

Anesthesia01237

Patient’s condition01237

Other (specify)01237

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10.2Were factors leading to the complication within the surgeon's control?

1Yes

0No (specify) ______

3Impossible to judge

10.3Did the surgical care meet standards of care at the time of the event?

1Yes

0No (elaborate in narrative summary)

3Impossible to judge

10.4Were the surgeon’s operative skills an issue in the claim?

1Yes(elaborate in narrative summary)

0No

3Impossible to judge

10.5Was informed consent an issue in the claim?

1Yes(elaborate in narrative summary)

0No

3Impossible to judge

10.6Did the recorded pre-operative assessment seem adequate?

1Yes

0No

3Impossible to judge

9Not applicable

10.7What was documented postoperative follow-up care?

1Adequate

2Inadequate

3Impossible to judge

10.8Did any of the following poor practice patterns play a role in this claim (check all that apply):

Failure to…

1adequately assess primary surgical problem before surgery

1adequately assess co-morbidities before surgery

1properly pursue a postoperative problem

1check test results

1properly pursue an abnormal symptom, sign or test result

1enlist support of proper consultant

1communicate with consultants

1see patient in a timely fashion

1follow patient long enough postoperatively

1communicate with patient and/or family

1stay within proper scope of practice

1 other poor practice (specify) ______

______

PREVENTION

10.9Was the complicationpreventable by surgical personnel?

1Preventable

2Probably preventable

3Possibly preventable

4Not preventable

77Unknown

10.10Would a better pre-operative assessment have prevented the complication?

1Would prevent

2Probably prevent

3Possibly prevent

4Would not prevent

77Impossible to judge

10.11Would performance or better performance of the surgical “time out” have prevented the complication?

1 Would prevent

2 Probably prevent

3 Possibly prevent

4 Would not prevent

77Impossible to judge

10.12Would better post surgical care have prevented the complication?

1Would prevent

2Probably prevent

3Possibly prevent

4Would not prevent

77Impossible to judge

10.13Would better communication have prevented the complication?

1Would prevent

2Probably prevent

3Possibly prevent

4Would not prevent

77Impossible to judge

If yes/probable/possibly, specify the communication problem:

1Physician to physician

1Physician to patient / family

1Physician and non-MD personnel

1Medical record or test results

1Other
(specify)______

10.14Was the lawsuit preventable by better communications?

1Preventable

2Probably preventable

3Possibly preventable

4Not preventable

77Unknown

DESCRIBE ANY COMMUNICATION ISSUES THAT OCCURRED:

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10.15Did any of the following occur?YesNoNo information in file

Finger pointing occurred between health care providers. 109

Defendant either was a poor witness or was perceived to

be a poor witness because of arrogant or combative attitude.109

Defendant either was a poor witness or was perceived

to be a poor witness because of language issues.109

Defendant was able to communicate well with patient & family.109

Defendant’s bedside manner was difficult.109

Defendant disclosed the adverse event to the patient or family.109

Defendant apologized to patient or family for adverse event.109

Defendant’s conduct was inappropriate or unprofessional. 109

If yes, specify:______

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From the Reviewer’s Perspective

10.16What was the main issue in the claim?

1Informed consent

2Diagnosis issue – preoperative
(diagnosis of patient condition wrong or delayed)

3Treatment issue – preoperative
(inappropriate treatment chosen; no treatment provided; treatment delayed / not timely)

4Technical misadventure during surgery

5Diagnosis of intraoperative complication (not diagnosed; diagnosed wrong)

6Diagnosis of postoperative complication (wrong or delayed or not diagnosed)

7Treatment of complication – wrong or delayed

8Failure of surgery to obtain desired outcome

98Other(specify) ______

From the Plaintiff’s Perspective

10.17Thinking about this case from the plaintiff’s perspective, would the plaintiff agree with your assessment of the main issue in this claim?

1Yes

0No, (specify difference)______

3Impossible to judge

10.18From the plaintiff’s perspective, are there any additional issues or events of which you believe we should be aware?

1Yes, (specify)______

0No

3Impossible to judge

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Section 11.Summary of Events - REQUIRED – DO NOT LEAVE THIS BLANK

11.1Specify the sequence of events and details not included elsewhere on the form. Describe the roles of surgical vs. non-surgical personnel (anesthesia, nursing, technicians, etc.) in the event and outcome. Providecomment on your assessment of the quality of surgical care. Please write legibly.

Sequence of Clinical Events

▪Patient’s Clinical Presentation/History

▪Initial Diagnosis

▪Surgical Plan

▪What Happened? (What was done correctly and what was in error.)

▪How were problems addressed?

▪Ultimate Clinical Outcome

Professional Assessment

▪Professional Assessment of Surgical Care

▪Liability Issues

▪Was Standard of Care Met? If no, be sure to elaborate.

▪What could have been done to reduce the likelihood of patient injury, dissatisfaction or legal action?

Any Additional Information of which You Believe We Should Be Aware

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