Original Article| Volume 28, ISSUE 2, P484-489, March 2023

The impact of system and diagnostic errors for medical litigation outcomes in orthopedic surgery

Published:December 07, 2021DOI:



      Medical litigation resulting from medical errors has a negative impact on health economics for both patients and medical practitioners. In medical litigation involving orthopedic surgeons, we aimed to identify factors contributing to plaintiff victory (orthopedic surgeon loss) through a comprehensive assessment.


      This retrospective study included 166 litigation claims against orthopedic surgeons using a litigation database in Japan. We evaluated the sex and age of the patient (plaintiff), initial diagnosis, diagnostic error, system error, the time and place of each claim that led to malpractice litigation, the institution's size, and clinical outcomes. The main outcome was the litigation outcome (acceptance or rejection) in the final judgment. Acceptance meant that the orthopedic surgeon lost the malpractice lawsuit. We conducted multivariable logistic regression analyses to examine the association of factors with an accepted claim.


      The median age of the patients was 42 years, and 65.7% were male. The litigation outcome of 85 (51.2%) claims was acceptance. The adjusted median indemnity paid was $151,818. The multivariable analysis showed that diagnostic error, system error, sequelae, inadequate medical procedure, and follow-up observation were significantly associated with the orthopedic surgeon losing the lawsuit. In particular, claims involving diagnostic errors were more likely to be acceptance claims, in which the orthopedic surgeon lost (adjusted odds ratio 16.7, 95% confidence intervals: 4.7 to 58.0, p < 0.001). All of the claims in which the orthopedic surgeon lost were associated with a diagnostic or system error, with the most common one being system error.


      System errors and diagnostic errors were significantly associated with acceptance claims (orthopedic surgeon losses). Since these are modifiable factors, it is necessary to take measures not only for individual physicians but also for the overall medical management system to enhance patient safety and reduce the litigation risk of orthopedic surgeons.
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        • Leape L.L.
        • Woods D.D.
        • Hatlie M.J.
        • Kizer K.W.
        • Schroeder S.A.
        • Lundberg G.D.
        Promoting patient safety by preventing medical error.
        J Am Med Assoc. 1998 Oct 28; 280: 1444-1447
        • Bosma E.
        • Veen E.J.
        • Roukema J.A.
        Incidence, nature and impact of error in surgery.
        Br J Surg. 2011 Nov; 98: 1654-1659
        • Studdert D.M.
        • Mello M.M.
        • Gawande A.A.
        • Gandhi T.K.
        • Kachalia A.
        • Yoon C.
        • Puopolo A.L.
        • Brennan T.A.
        Claims, errors, and compensation payments in medical malpractice litigation.
        N Engl J Med. 2006 May 11; 354: 2024-2033
        • Graber M.L.
        • Franklin N.
        • Gordon R.
        Diagnostic error in internal medicine.
        Arch Intern Med. 2005 Jul 11; 165: 1493-1499
        • Watari T.
        Malpractice claims of internal medicine involving diagnostic and system errors in Japan.
        Intern Med. 2021 Sep 15; 60: 2919-2925
        • Singh H.
        • Schiff G.D.
        • Graber M.L.
        • Onakpoya I.
        • Thompson M.J.
        The global burden of diagnostic errors in primary care.
        BMJ Qual Saf. 2017 Jun; 26: 484-494
        • Jena A.B.
        • Seabury S.
        • Lakdawalla D.
        • Chandra A.
        Malpractice risk according to physician specialty.
        N Engl J Med. 2011 Aug 18; 365: 629-636
        • Watari T.
        • Tokuda Y.
        • Mitsuhashi S.
        • Otuki K.
        • Kono K.
        • Nagai N.
        • Onigata K.
        • Kanda H.
        Factors and impact of physicians' diagnostic errors in malpractice claims in Japan.
        PLoS One. 2020 Aug 3; 15e0237145
        • Li H.
        • Dong S.
        • Liao Z.
        • Yao Y.
        • Yuan S.
        • Cui Y.
        • Li G.
        Retrospective analysis of medical malpractice claims in tertiary hospitals of China: the view from patient safety.
        BMJ Open. 2020 Sep 24; 10e034681
        • Machin J.T.
        • Hardman J.
        • Harrison W.
        • Briggs T.W.R.
        • Hutton M.
        Can spinal surgery in England be saved from litigation: a review of 978 clinical negligence claims against the NHS.
        Eur Spine J. 2018 Nov; 27: 2693-2699
        • Agout C.
        • Rosset P.
        • Druon J.
        • Brilhault J.
        • Favard L.
        Epidemiology of malpractice claims in the orthopedic and trauma surgery department of a French teaching hospital: a 10-year retrospective study.
        Orthop Traumatol Surg Res. 2018 Feb; 104: 11-15
        • Cichos K.H.
        • Ewing M.A.
        • Sheppard E.D.
        • Fuchs C.
        • McGwin Jr., G.
        • McMurtrie J.T.
        • Watson S.L.
        • Xu S.
        • Fryberger C.
        • Baker D.K.
        • Crabtree R.M.
        • Murphy A.B.
        • Vaughan L.O.
        • Perez J.L.
        • Sherrod B.A.
        • Edmonds B.W.
        • Ponce B.A.
        Trends and risk factors in orthopedic lawsuits: analysis of a national legal database.
        Orthopedics. 2019 Mar 1; 42: e260-e267
        • Rynecki N.D.
        • Coban D.
        • Gantz O.
        • Gupta R.
        • Ayyaswami V.
        • Prabhu A.V.
        • Ruskin J.
        • Lin S.S.
        • Beebe K.S.
        Medical malpractice in orthopedic surgery: a Westlaw-based demographic analysis.
        Orthopedics. 2018 Sep 1; 41: e615-e620
        • Gathen M.
        • Makridis K.G.
        • Giannoudis P.V.
        Profile of litigation for orthopaedic trauma.
        Injury. 2018 Jun; 49: 1001-1002
        • von Elm E.
        • Altman D.G.
        • Egger M.
        • Pocock S.J.
        • Gøtzsche P.C.
        • Vandenbroucke J.P.
        • Strobe Initiative
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
        J Clin Epidemiol. 2008 Apr; 61: 344-349
      1. What is diagnostic error? Society to improve diagnosis in medicine.
        (Available from:)
        • Otsuki K.
        • Watari T.
        Characteristics and burden of diagnostic error–related malpractice claims in neurosurgery.
        World Neurosurg. 2021 Apr; 148: e35-e42
        • Ahmed S.A.
        • DeFroda S.F.
        • Naqvi S.J.
        • Eltorai A.E.M.
        • Hartnett D.
        • Ruddell J.H.
        • Born C.T.
        • Daniels A.H.
        Malpractice litigation following traumatic fracture.
        J Bone Joint Surg Am. 2019 Apr 3; 101: e27
        • Ring J.
        • Talbot C.L.
        • Clough T.M.
        Clinical negligence in foot and ankle surgery: a 17-year review of claims to the NHS litigation authority.
        Bone Joint Lett J. 2014 Nov; 96-B: 1510-1514
        • Talbot C.L.
        • Ring J.
        • Holt E.M.
        Litigation relating to conditions affecting the shoulder and elbow: an analysis of claims against the National Health Service.
        Bone Joint Lett J. 2014 May; 96-B: 574-579
        • Ring J.
        • Talbot C.
        • Price J.
        • Dunkow P.
        Wrist and scaphoid fractures: a 17-year review of NHSLA litigation data.
        Injury. 2015 Apr; 46: 682-686
        • Ring J.
        • Talbot C.
        • Cross C.
        • Hinduja K.
        NHSLA litigation in hip fractures: lessons learnt from NHSLA data.
        Injury. 2017 Aug; 48: 1853-1857
        • Webster F.
        • Bremner S.
        • Jackson M.
        • Bansal V.
        • Sale J.
        The impact of a hospitalist on role boundaries in an orthopedic environment.
        J Multidiscip Healthc. 2012; 5: 249-256
        • Phy M.P.
        • Vanness D.J.
        • Melton 3rd, L.J.
        • Long K.H.
        • Schleck C.D.
        • Larson D.R.
        • et al.
        Effects of a hospitalist model on elderly patients with hip fracture.
        Arch Intern Med. 2005; 165: 796-801
        • Weinberg N.S.
        • Stason W.B.
        Managing quality in hospital practice.
        Int J Qual Health Care. 1998 Aug; 10: 295-302
        • Schiff G.D.
        Diagnosis and diagnostic errors: time for a new paradigm.
        BMJ Qual Saf. 2014 Jan; 23: 1-3
        • Sasao S.
        • Hiyama T.
        • Tanaka S.
        • Mukai S.
        • Yoshihara M.
        • Chayama K.
        Medical malpractice litigation in gastroenterological practice in Japan: a 22-yr review of civil court cases.
        Am J Gastroenterol. 2006 Sep; 101: 1951-1953