TYPE Original Research

PUBLISHED 01 June 2023

DOI 10.3389/fpubh.2023.1080525

Medical malpractice in hospitals—

OPEN ACCESS how healthcare staff feel
EDITED BY
Simone Grassi,
University of Florence, Italy
Shang-Feng Tsai 1,2,3,4, Chieh-Liang Wu 4,5, Yu-Ying Ho 6,
REVIEWED BY
Pei-Yi Lin 6, Ai-Chu Yao 6, Ya-Hui Yah 6, Chia-Min Hsiao 7,
Marcello Benevento, Yu Huei You 7, Te-Feng Yeh 8*† and Cheng-Hsu Chen 2,3,4*†
University of Bari Aldo Moro, Italy
Davide Ferorelli, 1
School of Medicine, National Yang-Ming University, Taipei, Taiwan, 2 Division of Nephrology,
University of Bari Medical School, Italy Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, 3 Department
Ilenia Bianchi, of Life Science, Tunghai University, Taichung, Taiwan, 4 Department of Post-Baccalaureate Medicine,
University of Florence, Italy College of Medicine, National Chung Hsing University, Taichung, Taiwan, 5 Department of Critical Care
Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, 6 Department of Nursing, Taichung
*CORRESPONDENCE
Veterans General Hospital, Taichung, Taiwan, 7 Office of Social Work, Taichung Veterans General
Cheng-Hsu Chen
Hospital, Taichung, Taiwan, 8 Department of Healthcare Administration, Central Taiwan University of
[email protected]
Science and Technology, Taichung, Taiwan
Te-Feng Yeh
[email protected]

These authors have contributed equally to this

†
Introduction: Literature is limited on quantified acute stress reaction, the
work
impact of event scale on medical staff when facing medical malpractice
RECEIVED 13January 2023 (MMP), and how to individually care for staff.
ACCEPTED 12 May 2023
PUBLISHED 01 June 2023 Methods: We analyzed data in the Taichung Veterans General Hospital from
CITATION October 2015 to December 2017, using the Stanford Acute Stress Reaction
Tsai S-F, Wu C-L, Ho Y-Y, Lin P-Y, Yao A-C, Yah Questionnaire (SASRQ), the Impact of Event Scale-Revised (IES-R), and the
Y-H, Hsiao C-M, You YH, Yeh T-F and Chen C-H
medical malpractice stress syndrome (MMSS).
(2023) Medical malpractice in hospitals—how
healthcare staff feel. Results and Discussion: Of all 98 participants, most (78.8%) were women. Most
Front. Public Health 11:1080525.
MMPs (74.5%) did not involve injury to patients, and most staff (85.7%) indicated
doi: 10.3389/fpubh.2023.1080525
receiving help from the hospital. The internal-consistency evaluations of the
COPYRIGHT
© 2023 Tsai, Wu, Ho, Lin, Yao, Yah, Hsiao, You,
three questionnaires showed good validity and reliability. The highest score
Yeh and Chen. This is an open-access article of IES-R was the construct of intrusion (30.1); the most severe construct of
distributed under the terms of the Creative SASRQ was “Marked symptoms of anxiety or increased arousal,” and the most
Commons Attribution License (CC BY). The
use, distribution or reproduction in other
were having mental and mild physical symptoms for MMES. A higher total IES-R
forums is permitted, provided the original was associated with younger age (<40 y/o), and more severe injury on patients
author(s) and the copyright owner(s) are (mortality). Those who indicated receiving very much help from the hospital
credited and that the original publication in this
journal is cited, in accordance with accepted
were those having significantly lower SASRQ sores. Our study highlighted that
academic practice. No use, distribution or hospital authorities should regularly follow up on staff’s response to MMP. With
reproduction is permitted which does not timely interventions, vicious cycles of bad feelings can be avoided, especially
comply with these terms.
in young, non-doctor, and non-administrative staff.

KEYWORDS

medical malpractice, medical dispute, medical malpractice stress syndrome,

posttraumatic stress disorder, Stanford Acute Stress Reaction Questionnaire,
Impact of Event Scale-Revised

Introduction
Medical malpractice refers to a negligent act, omission, or unintentional harm, injury,
or death to a patient caused by a medical or healthcare professional. Unfortunately, incidents
of medical malpractice are on the rise worldwide (1, 2). In America, 7.4% of physicians
receive a malpractice claim every year, with 1.6% having to pay for the claim (3). According
to an insurance company in Germany, 4,500 out of 108,000 (4.2%) insured doctors are
involved in medical disputes each year, with 30% ending in settlement and 10% appearing
in a civil court (4). In England, medical malpractice cases have also increased more than

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double over a 5-year period (from 2007 to 2012) (2). In Taiwan, Materials and methods
such incidence has also increased steadily (5, 6), and the number of
civil cases is nearly four times higher in 2007 than in 2004. The Institute and participants
negative side effects impact the healthcare system, with inadequate
physician subspecialties due to more and more judicial processes This is a retrospective study aimed at evaluating the impact of
(7). Physicians have dramatically increased their use of defensive medical malpractice on the staff at the Taichung Veterans General
medications over the past 20 years in order to mitigate the risk of Hospital (TCVGH). TCVGH is a public medical center in Taichung
malpractice lawsuits (8). However, the use of such medications can City, Taiwan, with 1,500 beds and approximately 5,500 employees.
lead to overdiagnosis and overtreatment, which can be considered It provides safe and high-quality medical services and serves as the
a form of medical error. The defensive practice also results in referral hospital for critically ill and complex cases. TCVGH is
increased direct and indirect medical costs (9–11). The combination ranked number one in Taiwan based on the case-mix index,
of medical errors, malpractice, and defensive medicine is often reflecting the complexity and risk level of diseases and treatments.
referred to as the ill-fated triad (8). Most recent studies on medical The hospital provides patient-centered care and has multiple cross-
malpractice focus on the history of physicians’ malpractice claims department centers for integrated care. Given this background, the
(12), the workload of medical staff, communication style (13, 14), impact of medical malpractice and legal proceedings on staff is a
specialties cattery (5, 15), levels of the hospital, and the court major concern for the hospital authorities, and monitoring, early
making the final judgment (3, 5, 16). There is limited research on intervention, and out-of-court settlements are important issues. In
the emotional experiences of medical staff who have been involved a previous study (23), clinical risk management could
in cases of medical malpractice. Furthermore, like in Japan (17), be successfully applied to this topic. Besides, the reporting system
medical malpractice-related mortality or injury is a crime under is a vital tool for clinical risk management according to Italian
Taiwan’s Criminal law code. The United States, Canada, and the experiences (24, 25).
United Kingdom all deal with medical practice as a common law In October 2015, TCVGH initiated an early warning and
heritage. The United States, Canada, and the United Kingdom reporting system to address potential medical disputes and
handle medical malpractice cases under the common law legal litigations. The primary objective of this system was to monitor and
system, while Taiwan treats it as a criminal matter. This approach provide early intervention to minimize medico-legal issues and care
can create significant pressure on medical staff during the practice for employees. For this study, data was collected on all staff,
of medicine. Despite this, there is a lack of research in Taiwan including doctors and non-doctors, who had experienced medical
exploring the emotional experiences of medical staff who have been malpractice issues from October 2015 to December 2017.
involved in cases of medical malpractice. Participants were asked to complete three questionnaires, namely,
Medical malpractice stress syndrome (MMSS) is a term coined the Stanford Acute Stress Reaction Questionnaire (SASRQ), the
only recently to describe what happens when medical staff face Impact of Event Scale-Revised (IES-R), and the Medical Malpractice
medical malpractice (18). Apart from anxiety and depression, Stress Syndrome (MMSS) questionnaire to evaluate the impact of
MMSS includes perturbations in inflammatory states, immune medical malpractice. Only those who completed all three
dysregulation, and endocrine dysfunction (19). The IES-R questionnaires were included in the analysis. The study was
questionnaire was first created by Weiss et al., in 1997 to evaluate approved by the Ethics Committee of the Taichung Veterans
the impact of a specific event (20). IES-R is a good tool for General Hospital (IRB number: CE18097A), and all methods were
evaluating individuals with or without posttraumatic stress disorder performed in accordance with relevant guidelines and regulations.
(PTSD) (21). The Stanford Acute Stress Reaction Questionnaire
(SASRQ) was created >20 years ago (22) and has been a valid and
reliable measure of acute stress (22). Undoubtedly, medical staff Definition of variables and outcomes
who are involved in medical malpractice are experiencing PTSD (IES-R, SASRQ, and MMSS)
and acute stress. However, no study using SASRQ and IES-R to
evaluate their feelings or response to medical malpractice has The baseline data that we collected from participants included
been reported. their age, gender, degree (bachelor’s, master’s, or Doctor of
Medical malpractice is a global issue, and in Taiwan, medical Philosophy), religion, and marital status (unmarried, divorced,
staff who are involved in medical malpractice may face criminal widowed, or married). We also gathered information on their work
charges under the Criminal Law Code. Despite the gravity of the status and medical malpractice, including whether they were in an
situation, no studies have been conducted on the emotional executive role or not, their job type (doctor or non-doctor), job
experiences of healthcare staff facing medical malpractice charges. tenure (less than 2 years, 2–10 years, 10–20 years, or more than
Due to the lack of a definitive list to describe medical malpractice 20 years), the severity of injury to patients, and whether they
stress, we employed the MMES, SASRQ, and IES-R to investigate received any help from the institute (not at all, a little, or a lot). The
the psychological effects of medical malpractice on healthcare staff. definition of “help” is based on staff members’ subjective feelings.
We analyzed potential background factors associated with anxiety At our institute, when medical staff members are involved in
or stress, as well as the extent to which hospital authorities provided medical malpractice, the chief of their department and social
support. By gathering this information, we hope to make workers reach out to provide counseling and mental support. If
recommendations to hospital authorities on effective measures to there are concerns about a lawsuit, lawyers from our institute also
support medical staff and deliver timely interventions. provide further support.

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Questionnaire on the Impact of Event SPSS Statistics version 23, and statistical significance was set at
Scale-Revised (IES-R) p < 0.05.

IES-R was created by Weiss et al. in 1997 to evaluate the impact of

a specific event (20). The major characteristic of PTSD is the Results
distressing oscillation between intrusion and avoidance. There are
three constructs (philosophy) (a total of 22 questions) of evaluation, Baseline characteristics of all participants
including intrusion, avoidance, and hyperarousal. This IES-R has been
cited 6,697 times and is widely used to evaluate PTSD. The score of The data from the remaining 98 participants were analyzed after
each question is zero for the least severe and four for the most severe two participants did not complete all questionnaires. Most participants
conditions. The total score ranges from zero to 88. If the total score is (78.8%) were women, and distributions across age ranges were similar:
>32, the diagnosis of PTSD is strongly suggested (26). In our current 39.8% of <29 y/o, 24.5% of 30–39 y/o, and 35.7% of ≥40 y/o (Table 1).
study, we used the Chinese version of the Impact of Event Scale- Most of them were bachelor’s degree holders (77.6%), non-executive
Revised (CIES-R), which has a high Cronbach’s alpha score (0.83– workers (86.9%), and non-doctors (79.6%). More than one-third of
0.89). The high Cronbach’s alpha score of CIES-R indicates an them had a job tenure between 2 and 10 years. Most medical
acceptable high internal-consistency reliability in our population. malpractices (74.5%) occurred without patient injury. Most staff
SASRQ was created >20 years ago and it is the most widely used indicated receiving help from the hospital (21.4% with a lot of help,
questionnaire of this kind worldwide (22). It has different versions and and 64.3% with a little help).
has been used for >90 publications (27). It was initially a 98-item Internal consistency reliability evaluations of the three
questionnaire, and subsequently reduced to a 30-item questionnaire questionnaires (IES-R, SASRQ, and MMSS) showed good validity and
to fit DSM-IV Acute Stress Disorder criteria. The new version has high reliability (Table 2). All Cronbach’s Alpha scores in IES-R were > 0.9,
predictive power for PTSD. It includes four groups: dissociation, specifically 0.969 for all IES-R, 0.936 for the construct of intrusion,
re-experiencing of the trauma, avoidance of reminders of the trauma, 0.906 for the construct of avoidance, and 0.912 for the construct of
and marked symptoms of anxiety or increased arousal. It is also used hyperarousal. All Cronbach’s Alpha scores in SASRQ also showed
to evaluate impairment in social or occupational functioning. For each good validity: 0.972 for all SASRQ scores, 0.920 for the construct of
item of the questionnaire, the least severe score is zero, and the most dissociation, 0.844 for the construct of re-experiencing the trauma,
severe score is five (5-point Likert scale). SASRQ represents a good and 0.929 for the construct of avoidance of reminders of the trauma.
research checklist with very good internal consistency (0.80–0.95) and Similarly, Kuder–Richardson’s 20 scores for MMS showed good
test–retest reliability (0.69) (22). A total score (range 0–150) is validity: 0.914 for mental symptoms, 0.912 for physical symptoms, and
calculated, and high scores suggest serious acute stress. In this study, 0.789 for interpersonal relationships.
we used the Chinese version of SASRQ, which was also used in our
previous study (28).
Responses of medical staff to medical
malpractice
Questionnaire of medical malpractice
stress syndrome (MMSS) Detailed results of the IES-R for PTSD are shown in Table 3, with
the summary listed in Table 2. The standardized mean value of all
MMSS is considered to be one aspect of PTSD, and healthcare IES-R scores was 28.8. Among them, the highest score was the
staff may experience it in the form of psychological, physical, and construct of intrusion (30.1), followed by the construct of avoidance
behavioral trauma. As there is no single definitive list of symptoms, (28.4) and hyperarousal (27.5). In general, detailed impact scores of
we used the most frequently cited indications for our study (26, 29). medical malpractices were not high (Table 3). Of all the 22 events’
They included mental symptoms (14 questions), physical symptoms scores, most were less than moderate severity at <1.5 of the mean
(15 questions), and the impairment of interpersonal relationships (5 score, except two items: “Item 1: Any reminder brought back feelings
questions). All questions had to be responded to with only “yes” about it (1.58 of the score)” and “Item 21: I felt watchful or on-guard
or “no.” (1.73 of the score).”
Detailed results of the impact of SASRQ on medical malpractice
are shown in Table 4 and the summary is listed in Table 2. The
Statistical analyses standardized mean value of all SASRQ was 52.0, which represented
the level of moderate severity (Table 2). The most severe construct of
The presentation of continuous variables was done as SASRQ was “Marked symptoms of anxiety or increased arousal” (62.9
mean ± standard deviation, while the presentation of categorized of the standardized mean value). The least severe construct of SASRQ
variables was done as a percentage (%). To compare differences was “Impairment in social or occupational functioning” (37.0 of the
between continuous variables, we used the independent samples standardized mean value). Of all the 30 items of SASRQ (Table 4), the
student t-test. To evaluate possible associated factors of outcomes highest score was Item 23: I would suddenly act or feel as if the
for medical malpractice, we used Analysis of Variance (ANOVA). medical malpractice is happening again” (3.17 of the mean score),
To evaluate the internal consistency reliability of IES-R and followed by “Item 2: I felt restless” (2.69 of the mean score) and “Item
SASRQ, we used Cronbach’s Alpha score, while for MMSS, 1: I had difficulty falling or staying asleep” (2.56 of the mean score).
we used Kuder–Richardson 20. All data were analyzed using IBM The lowest score was “Item 10: I did not have the usual sense of whom

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TABLE 1 Baseline data of participants.

and “tension” (72.4%). Of all the 15 physical symptoms, more than
Variable Number Percentage half felt “fatigue” (76.5%), “tiredness” (71.4%), “anxiety” (66.3%), and
“tense muscles” (55.1%). Very few staff agreed with “alcohol
Gender
consumption or drug use” (12.2%), “worsening of the original disease”
 Female 77 78.6
(16.3%), “chest pains” (22.4%), and “elevated blood pressure” (22.4%).
 Male 21 21.4 Of all the five interpersonal relationships, 64.3% indicated “offer much
Age (y/o) more medical care to avoid medical malpractice” and only 23.5%
 <29 39 39.8 experienced “isolation from family and co-workers.”

 30–39 24 24.5

≥40
  35 35.7 Association analyses for the outcome of
Degree medical malpractice
 Bachelor 76 77.6
The results of the bivariate analysis to study associations between
 Master, or Doctor of 22 22.4
variables and IES-R are shown in Table 6. A high total IES-R was
Philosophy
associated with a statistical significance of young age (< 40 y/o vs. ≥
Marriage
40 y/o) and a more severe patient injury from medical malpractice
 Unmarried, divorced, 53 54.1 (mortality > no or major injury), mainly with the constructs of
widower or widow, or intrusion and avoidance. In addition, the hyperarousal construct was
Married 45 45.9 associated with a statistical significance of more severe patient injury
Executive class
from medical malpractice (mortality > no or major injury). Patient
death was significantly associated with the total IES-R and with all
 No 85 86.7
three constructs (intrusion, avoidance, and hyperarousal).
 Yes 13 13.3 The results of the bivariate analysis to study associations between
Job variables and the SASRQ are shown in Table 7. Total SASRQ scores
 Doctor 20 20.4 and nearly all constructs were not associated with variables.
Dissociation was associated with the female gender and a non-doctor
 Nurse 78 79.6
status. Those staff who received very much help from the hospital were
Job tenure (years) associated with a significantly lower total SASRQ score, dissociation,
 <2 24 24.5 re-experiencing of the trauma, and marked symptoms of anxiety or
 2–10 34 34.7 increased arousal.
 10–20 17 17.3

 >20 23 23.5
Discussion
Religion

 No 49 50.0 We analyzed the impact of medical malpractice on staff, as well as

 Yes 49 50.0
the effects of care received from our institute and other associated
factors on staff ’s stress due to medical malpractice. When staff
Any injury of this medical malpractice to patients
members encounter medical malpractice, they often experience
 No injury 73 74.5 mental and physical symptoms while still needing to maintain their
 Major injury 11 11.2 professional competence to avoid further incidents. Without timely
 Mortality 14 14.3 intervention, this can become a vicious cycle. Additionally, different
background conditions of the staff and different types of medical
Did the help provided by the hospital work for you?
malpractice can lead to different outcomes. The findings of this study
 Not at all 14 14.3
highlight the importance of regular monitoring and providing
 A little 63 64.3 appropriate care for staff based on their unique backgrounds and
 Very much 21 21.4 circumstances to ensure their well-being and protection.
In this survey, we found that scores from IES-R were not high. The
highest score was the construct of intrusion (30.1). Most score levels
I am.” (1.16 of the mean score), followed by “Item 13: I experienced were lower than moderate severity, typically <1.5 of the mean score,
myself as though I were a stranger.” (1.45 of the mean score), and except “Item 1: Any reminder brought back feelings about it (1.58 of
“Item 16: I had problems remembering important details about the score)” and “Item 21: I felt watchful or on-guard (1.73 of score).” As
medical malpractice.” (1.54 of the mean score). for the results of the impact of SASRQ, the most severe construct of
Detailed results of MMES for medical malpractice are shown in SASRQ was “Marked symptoms of anxiety or increased arousal.” Most
Table 5. Of all the 14 mental symptoms, less than half of the staff felt were not severe SASRQ scores. For MMSE, more than 70% of staff felt
“hopeless” (39.8%), “apathy” (41.8%), “a sense of being shunned by “frustration” (79.6%) and “tension” (72.4%). Of all the 15 physical
colleagues” (21.4%), and “a sense of having been assaulted” (41.8%). symptoms, more than half of the staff felt “fatigue” (76.5%), “tiredness”
On the contrary, more than 70% of the staff felt “frustration” (79.6%) (71.4%), “anxiety” (66.3%), and “tense muscles” (55.1%). Very few staff

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TABLE 2 Scores of different constructs (philosophy) from SASRQ, IES-R, and MMSS.

Variables Range Min Max Mean Standard Standardized Cronbach’s

deviation mean Alpha
IES-R 0 ~ 88 0 88 25.3 17.5 28.8 0.969

 Intrusion 0 ~ 32 0 32 9.6 6.6 30.1 0.936

 Avoidance 0 ~ 32 0 32 9.1 6.2 28.4 0.906

 Hyperarousal 0 ~ 24 0 24 6.6 5.4 27.5 0.912

SASRQ 0 ~ 150 0 118 61.4 29.4 52.0 0.972

 Dissociation 0 ~ 50 0 40 18.0 9.6 45.1 0.920

 Re-experiencing the trauma 0 ~ 30 0 27 13.5 6.2 50.2 0.844

 Avoidance of reminders of the trauma 0 ~ 30 0 28 12.3 7.1 43.8 0.929

 Marked symptoms of anxiety or increased

0 ~ 30 0 22 13.8 6.6 62.9 0.908
arousal

 Impairment in social or occupational

0 ~ 10 0 10 3.7 2.2 37.0 0.788
functioning

MMSS KR 20

 Mental symptoms 0.914

 Physical symptoms 0.912

 Interpersonal relationship 0.789

Cronbach’s Alpha or Kuder–Richardson 20: for the evaluation of internal consistency reliability.

TABLE 3 Results of the Impact of Event Scale-Revised (IES-R) for post-traumatic stress disorder (PTSD).

Construct Questions Mean Standard

deviation
Total score 25.32 17.47

I 1. Any reminder brought back feelings about it. 1.58 1.04

I 2. I had trouble staying asleep. 1.19 1.03

I 3. Other things kept making me think about it. 1.44 1.07

H 4. I felt irritable and angry. 1.23 1.08

A 5. I avoided letting myself get upset when I thought about it or was reminded of it. 1.42 1.03

I 6. I thought about it when I did not mean to. 1.37 0.96

A 7. I felt as if it had not happened or wasn’t real. 0.89 0.96

A 8. I stayed away from reminders about it. 1.23 0.95

I 9. Pictures about it popped into my mind. 1.26 0.94

H 10. I was jumpy and easily startled. 0.95 1.08

A 11. I tried not to think about it. 1.27 1.05

A 12. I was aware that I still had a lot of feelings about it, but I did not deal with them. 1.14 0.91

A 13. My feelings about it were kind of numb. 0.96 0.99

I 14. I found myself acting or feeling as though I was back at that time. 0.85 0.93

H 15. I had trouble falling asleep. 1.02 1.11

I 16. I had waves of strong feelings about it. 1.10 1.00

A 17. I tried to remove it from my memory. 1.16 1.03

H 18. I had trouble concentrating. 0.85 0.97

H 19. Reminders of it caused me to have physical reactions, such as sweating, trouble breathing, 0.82 1.05
nausea, or a pounding heart.

I 20. I had dreams about it. 0.84 0.97

H 21. I felt watchful or on guard. 1.73 1.17

A 22. I tried not to talk about it. 1.02 1.07

A, avoidance; H, hyperarousal; I, intrusion.

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TABLE 4 Results of the Stanford Acute Stress Reaction Questionnaire (SASRQ).

Construct Mean Standard

deviation
Total scores 61.36 29.43

M 1. I had difficulty falling or staying asleep 2.56 1.27

M 2. I felt restless 2.69 1.26

D 3. I felt a sense of timelessness. 2.23 1.32

D 4. I was slow to respond. 2.34 1.18

A 5. I tried to avoid feelings about the medical malpractice. 2.29 1.29

R 6. I had repeated distressing dreams of the medical malpractice. 1.76 1.25

R 7. I felt extremely upset if exposed to events that reminded me of an aspect of the medical malpractice. 2.55 1.41

M 8. I would jump in surprise at the least thing. 1.94 1.40

9. The medical malpractice made it difficult for me to perform work or other things I needed to do. 2.02 1.27

D 10. I did not have the usual sense of who I am. 1.16 1.19

A 11. I tried to avoid activities that reminded me of the medical malpractice. 2.04 1.40

M 12. I felt hypervigilant or “on edge” 2.40 1.41

D 13. I experienced myself as though I were a stranger. 1.45 1.29

A 14. I tried to avoid conversations about the medical malpractice. 1.95 1.38

R 15. I had a bodily reaction when exposed to reminders of the medical malpractice. 1.81 1.40

D 16. I had problems remembering important details about the medical malpractice. 1.54 1.29

A 17. I tried to avoid thoughts about the medical malpractice. 1.94 1.42

D 18. Things I saw looked different to me from how I know they really looked. 2.12 1.30

R 19. I had repeated and unwanted memories of the medical malpractice. 1.93 1.43

D 20. I felt distant from my own emotions. 1.79 1.28

M 21. I felt irritable or had outbursts of anger. 2.31 1.38

A 22. I avoided contact with people who reminded me of the medical malpractice. 2.00 1.38

R 23. I would suddenly act or feel as if the medical malpractice was happening again. 3.17 1.35

D 24. My mind went blank. 1.79 1.26

D 25. I had amnesia for large periods of the flood. 1.82 1.24

I 26. The flood caused problems in my relationships with other people. 1.68 1.21

M 27. I had difficulty concentrating. 1.94 1.25

D 28. I felt estranged or detached from other people. 1.79 1.28

I 29. I had a vivid sense that the medical malpractice was happening all over again. 2.33 1.36

A 30. I tried to stay away from places that reminded me of the medical malpractice. 2.04 1.43

agreed on “alcohol consumption or drug use” (12.2%), “worsening of basis. Authorities of the medical institute should be aware of the
the original disease” (16.3%), “chest pains” (22.4%), and “elevated basic aspects of medical professional liability and should help to
blood pressure” (22.4%). Most were under mental stress, but they were control damages from medical malpractice (30). In this study,
able to self-adjust without substance abuse. These findings were we found that female staff (all nurses) and non-doctors showed
reasonable considering that medical malpractice and likely lengthy higher scores of SASRQ. Younger staff encountering more severe
judicial processes were stressful for the staff. Most medical staff patient injuries also showed similar high scores. In summary, young
(85.9%) spend an average of 4.7 years to prove their innocence (5). female staff at non-doctor and non-administrative positions
This condition is especially serious in Taiwan because of the potential encountering severe patient injury were those showing the highest
for criminal prosecution and conviction. In our institute, the hospital’s risks of stress and anxiety. The results are reasonable since medical
care for staff was good and most of them (85.7%) felt helped by the staff with longer job tenures (also with a better chance to
hospital. Even under mental stress, our staff were still able to handle be administrators) were more familiar with and more educated
the situation. about medical malpractice. As for doctors and non-doctors,
Medical malpractice can be committed by various healthcare physicians were more used to facing medical malpractice and the
providers, including doctors, nurses, nursing assistants, impact on them was less. Notably, doctors at this institute receive
administrators, and others who provide care for patients on a daily regular training on how to handle potential disputes, which may

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TABLE 5 Results of medical malpractice stress syndrome (MMSS).

Variables Yes No
N % N %
Mental symptoms

 Anger 49 50.0 49 50.0

 Outrage 59 60.2 39 39.8

 Frustration 78 79.6 20 20.4

 Tension 71 72.4 27 27.6

 Isolation/distrust 63 64.3 35 35.7

 Negative self-image 55 56.1 43 43.9

 Depression 65 66.3 33 33.7

 Self-doubt 57 58.2 41 41.8

 Hopelessness 39 39.8 59 60.2

 Apathy 41 41.8 57 58.2

 Excessive worry 50 51.0 48 49.0

 Decreased interest in recreation and/or work 55 56.1 43 43.9

 Sense of being shunned by colleagues 21 21.4 77 78.6

 Sense of having been assaulted 41 41.8 57 58.2

Physical symptoms

 Fatigue 75 76.5 23 23.5

 Inability to concentrate 45 45.9 53 54.1

 Anxiety 65 66.3 33 33.7

 Tiredness 70 71.4 28 28.6

 Tense muscles 54 55.1 44 44.9

 Insomnia 47 48.0 51 52.0

 Loss of sex-drive 27 27.6 71 72.4

 Alcohol consumption or drug use 12 12.2 86 87.8

 Gastrointestinal upset 42 42.9 56 57.1

 Chest pains 22 22.4 76 77.6

 Changes in appetite 36 36.7 62 63.3

 Elevated blood pressure 22 22.4 76 77.6

 Headache 37 37.8 61 62.2

 Decreased immunity 29 29.6 69 70.4

 Worsening of the original disease 16 16.3 82 83.7

Interpersonal relationship

 Feelings of betrayal 44 44.9 54 55.1

 Isolation from family and co-workers 23 23.5 75 76.5

 Doubting my ability 46 46.9 52 53.1

 Cannot trust patients and even everyone 44 44.9 54 55.1

 Offer much more medical care to avoid medical malpractice 63 64.3 35 35.7

have influenced their responses. Medical disputes for non-doctor developed a greater ability to manage the associated stress and
medical staff have been better studied in recent years (31–34). emotional impact. Consequently, our findings suggest that older
Nurses are undoubtedly the healthcare professionals who have the staff members were less likely to have higher scores on the
most contact with patients and, as a result, are most likely to SASRQ. In conclusion, hospital policymakers may wish to direct
become involved in incidents. With respect to age, it is noteworthy their attention toward younger non-doctor staff members and
that older medical staff members are more likely to have experienced provide them with early interventions in order to prevent serious
medical malpractice incidents in the past and, thus, may have incidents of medical malpractice from occurring. This proactive

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Tsai et al. 10.3389/fpubh.2023.1080525

TABLE 6 Logistic regression for the association between possible variables and the Impact of Event Scale-Revised (IES-R).

Total IES-R Intrusion Avoidance Hyperarousal

Mean SD Mean SD Mean SD Mean SD
Gender t
1.436 1.305 1.520 0.883

Female 30.14 16.06 11.29 6.11 11.33 5.53 7.52 5.20

Male 24.00 21.66 9.17 8.16 8.48 8.10 6.35 6.09

Age (y/o) A
3.666* 3.774* 3.496* 2.779

<29 28.26 18.45 10.95 6.92 10.03 6.46 7.28 5.74

30–39 29.58 18.51 10.96 7.23 10.71 6.55 7.92 5.48

≥40 19.11 13.99 7.23 5.16 6.94 5.25 4.94 4.61

Degree t
−0.331 −0.609 0.463 −0.863

Bachelor 24.23 16.34 8.86 6.16 9.64 5.68 5.73 5.30

Master, or Doctor
25.63 21.31 9.84 8.10 8.93 7.98 6.86 5.73
of Philosophy

Marriaget 0.518 0.269 1.004 0.221

Unmarried,
divorced, widower 26.33 15.32 9.82 5.93 9.78 5.14 6.73 5.06
or widow, or

Married 24.45 19.84 9.45 7.40 8.51 7.32 6.49 5.82

Executive class t
−0.699 −0.678 −0.057 −1.378

No 22.15 18.08 8.46 6.82 9.00 6.35 4.69 5.58

Yes 25.80 12.83 9.80 5.08 9.11 5.61 6.89 3.50

Job t
1.031 1.045 1.348 0.834

Doctor 29.75 22.79 11.00 8.51 11.25 8.57 7.50 6.42

Non-doctor 24.18 15.81 9.27 6.05 8.54 5.41 6.37 5.12

Job tenure (years) A

0.432 0.428 0.541 0.346

<2 27.83 20.73 10.38 8.10 10.25 6.94 7.21 6.16

2–10 26.15 16.85 9.94 5.88 9.29 6.05 6.91 5.62

11–20 24.12 14.97 9.71 6.69 8.12 5.54 6.29 4.18

> 20 22.35 17.00 8.30 6.09 8.30 6.38 5.74 5.20

Religiont −0.686 −0.411 −0.274 −1.412

No 24.10 20.34 9.35 7.50 8.92 7.16 5.84 6.39

Yes 26.53 14.14 9.90 5.64 9.27 5.22 7.37 4.09

Any injury of this

medical
7.151** 5.315** 10.013*** 4.811**
malpractice to
patients A

No injury 22.75 15.35 8.70 5.99 8.05 5.29 6.00 4.77

Major injury 22.73 17.50 9.27 6.78 7.91 6.75 5.55 5.68

Mortality 40.71 20.93 14.71 7.70 15.43 7.04 10.57 6.80

Post hoc (Scheffe) 3>1,2 3>1 3>1,2 3>1

Did the help 2.019 1.740 1.720 2.175

provided by the
hospital work for
youA

Not at all 33.00 14.60 12.43 5.43 11.64 5.50 8.93 4.80

A little 25.02 15.89 9.44 6.12 8.98 5.52 6.59 5.04

Very much 21.10 22.33 8.29 8.31 7.71 8.24 5.10 6.40
t, t-test; A, analysis of variance, ANOVA.

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Tsai et al. 10.3389/fpubh.2023.1080525

TABLE 7 Logistic regression for the association between possible variables and Stanford Acute Stress Reaction Questionnaire (SASRQ).

Total SASRQ Dissociation Re- Avoidance of Marked Impairment in

experiencing reminders of symptoms of social or
the trauma the trauma anxiety or occupational
increased functioning
arousal
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Gender t
−1.340 −2.702** −0.293 −1.293 −0.132 −0.962

Male 53.76 30.31 13.14 9.66 13.19 6.36 10.48 7.32 13.67 6.56 3.29 2.26

Female 63.43 25.16 19.35 7.95 13.64 5.49 12.74 6.27 13.88 6.92 3.82 2.22

Age (y/o) A
0.478 1.260 0.086 0.127 0.459 0.730

<29 64.90 27.55 19.90 9.00 13.85 5.79 12.59 6.46 14.54 6.22 4.03 2.24

30–39 59.79 31.85 16.46 10.66 13.46 7.16 12.42 7.30 13.83 6.88 3.63 2.37

≥40 58.49 30.19 17.00 9.51 13.26 5.98 11.77 7.89 13.06 6.93 3.40 2.19

Degrees t
−0.315 −0.688 0.396 0.114 −0.416 −0.697

Bachelor 59.91 31.34 16.77 10.17 14.00 6.60 12.41 7.48 13.32 6.92 3.41 2.32

Master or Doctor of
61.78 22.13 18.38 7.54 13.41 4.40 12.21 5.93 13.99 5.47 3.79 2.02
Philosophy

Marriaget −0.536 −1.137 −0.077 −0.495 0.194 −0.963

Unmarried, divorced,
59.62 29.81 16.82 9.69 13.49 6.02 11.87 7.29 13.98 6.51 3.47 2.40
widower or widow, or

Married 62.83 29.22 19.04 9.53 13.58 6.38 12.58 7.02 13.72 6.78 3.91 2.06

Executive class t
−0.057 −0.100 0.269 −0.346 0.005 0.243

No 60.92 30.13 17.77 9.78 13.85 6.44 11.62 7.27 13.85 6.70 3.85 2.29

Yes 61.42 25.43 18.06 8.94 13.49 4.00 12.35 6.42 13.84 6.15 3.68 2.08

Job t
−1.828 −3.228** −0.724 −1.165 −1.130 −1.467

Doctor 50.75 26.95 12.10 7.91 12.65 6.11 10.60 7.07 12.35 6.95 3.05 2.21

Non-doctor 64.08 29.58 19.54 9.48 13.77 6.19 12.68 7.13 14.22 6.50 3.87 2.24

Job tenure (years) A

0.147 0.344 0.053 0.135 0.318 0.780

<2 58.42 33.14 18.21 10.69 12.04 7.03 11.79 7.70 12.67 6.59 3.71 2.35

2–10 61.85 27.24 17.79 9.63 14.03 5.31 12.53 6.10 13.79 6.65 3.71 2.26

11–20 64.59 26.97 18.12 8.22 14.82 6.32 12.24 7.47 15.53 6.46 3.88 2.03

>21 61.30 31.79 18.09 10.05 13.43 6.33 12.35 8.11 13.87 6.82 3.57 2.41

Religiont −0.331 −0.271 −0.049 −0.211 −0.518 −0.852

No 60.37 30.69 17.76 10.15 13.51 6.25 12.10 7.19 13.49 6.82 3.51 2.36

Yes 62.35 28.40 18.29 9.18 13.57 6.12 12.41 7.15 14.18 6.43 3.90 2.14

Any injury of this 0.938 1.768 0.200 1.264 0.866 1.285

medical malpractice to
patientsA

No injury 63.58 30.56 19.08 9.91 13.75 6.40 12.56 7.30 14.30 6.85 3.88 2.27

Major injury 51.55 22.70 14.82 7.53 13.27 5.18 9.09 5.11 11.64 5.85 2.73 2.05

Mortality 57.50 27.69 19.08 8.92 13.75 5.87 12.56 7.39 14.30 5.79 3.88 2.21

Did the help provided 4.211* 4.481* 5.358** 2.535 3.698* 2.020
by the hospital work for
youA

Not at all 66.79 29.28 18.00 9.57 16.14 5.99 13.71 8.14 15.21 6.45 3.71 2.43

A little 65.48 27.58 19.78 9.14 14.13 5.73 12.94 6.75 14.65 6.05 3.98 2.23

Very much 45.38 30.72 12.76 9.62 10.05 6.34 9.24 7.09 10.48 7.47 2.86 2.06

Post hoc 2>3 1,2>3 2>3

SD, Standard deviation; t, t-test; A, analysis of variance, ANOVA; *p < 0.05; **p < 0.01.

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Tsai et al. 10.3389/fpubh.2023.1080525

approach would be of great benefit to minimize negative impacts Ethics statement

on medical staff members. In our institute, the chief of the
department and social worker initially reach out to the affected staff The studies involving human participants were reviewed and
members to offer support, which includes a review of the incident, approved by CE18097A. The patients/participants provided their
counseling, and mental health support. If any legal concerns were written informed consent to participate in this study. Written
raised, our hospital’s legal team is also available to provide further informed consent was obtained from the individual(s) for the
support to the staff members. Based on the results of this study, it publication of any potentially identifiable images or data included in
is evident that this support system has proven to be effective. this article.
This study is subject to certain limitations. Firstly, we did not
collect data on the specialties of the physicians involved in the
incidents. Secondly, we lacked information on the socio-demographic Author contributions
characteristics of the plaintiffs. Thirdly, the frequency with which
medical staff members had previously experienced incidents of S-FT, T-FY, and C-HC: conceptualization and data curation.
medical malpractice was not recorded. Fourthly, the sample size was C-LW and T-FY: methodology. Y-YH and T-FY: software. C-LW and
small and not well-balanced in terms of participant characteristics. C-HC: validation and writing—review and editing. S-FT and T-FY:
Finally, it is possible that some staff members may have forgotten formal analysis and writing—original draft preparation. Y-YH, P-YL,
certain details of the incident due to the time lapse between the A-CY, Y-HYah, and C-MH: investigation. C-LW and Y-HYou:
occurrence of the incident and their completion of the questionnaire. resources. C-LW, T-FY, and C-HC: supervision and funding
However, we believe that any such bias is likely to be minor since all acquisition. S-FT and Y-HYah: project administration. All authors
medical staff members claimed that they would not forget the contributed to the article and approved the submitted version.
emotional impact of such incidents.

Funding
Conclusion
This study was supported by grant TCVGH-CTUST1077702 from
Our study underscores the importance of hospital authorities the Taichung Veterans General Hospital and Central Taiwan
regularly monitoring staff members’ responses to incidents of University of Science and Technology.
medical malpractice. The provision of mechanisms for reporting
near misses, coupled with ongoing staff training, can help to
mitigate the incidence of adverse events associated with healthcare Conflict of interest
practices. With effective and timely interventions, it is possible to
break the vicious cycle of medical malpractice. Based on the The authors declare that the research was conducted in the
findings of this study, hospital authorities should develop a strategic absence of any commercial or financial relationships that could
plan aimed at preventing incidents of medical malpractice by be construed as a potential conflict of interest.
prioritizing the care of young, non-doctor, and non-administrative
medical staff members.
Publisher’s note
Data availability statement All claims expressed in this article are solely those of the authors
and do not necessarily represent those of their affiliated organizations,
The original contributions presented in the study are included in or those of the publisher, the editors and the reviewers. Any product
the article/supplementary material, further inquiries can be directed that may be evaluated in this article, or claim that may be made by its
to the corresponding authors. manufacturer, is not guaranteed or endorsed by the publisher.

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