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 Right2Left 7 Unknown side of body
2.7Anatomical description:
1 Bones2 Nerves
3 Joints5 Spine
6 Skin8 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)______
1
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
1
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 Room6Ward/floor
1Pre-incision7Post discharge
2Intra-procedure8Impossible to
3In transitjudge
4PACU98Other (specify)
5ICU
6.4Where did the injury become apparent?
0Emergency Room6Ward/floor
1Pre-incision7Post discharge
2Intra-procedure8Impossible to
3In transitjudge
4PACU98Other (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
Pain3 2 1 77
Instability3 2 1 77
Functionality3______ 2 1 77
Weakness3 2 1 77
Stiffness3 2 1 77
Crepitus3 2 1 77
Sensation3 2 1 77
Range of motion3 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
8.101Nerve 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
Surgery01237
Anesthesia01237
Patient’s condition01237
Other (specify)01237
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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. 109
Defendant either was a poor witness or was perceived to
be a poor witness because of arrogant or combative attitude.109
Defendant either was a poor witness or was perceived
to be a poor witness because of language issues.109
Defendant was able to communicate well with patient & family.109
Defendant’s bedside manner was difficult.109
Defendant disclosed the adverse event to the patient or family.109
Defendant apologized to patient or family for adverse event.109
Defendant’s conduct was inappropriate or unprofessional. 109
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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