Medical malpractice claims offer patients who have experienced harm as the result of negligence by physicians, hospitals and other health care providers the opportunity to obtain financial compensation. Negligence in malpractice cases is defined as the failure to conform to an accepted standard of care, i.e., in one common formulation, to fail to behave as a reasonable physician would in a similar circumstance¹.

In the US and many other countries, allegations of malpractice are litigated in civil courts, with patient-plaintiffs carrying the burden of proving that their caregivers acted in a negligent fashion. Recent years have seen growing interest in identifying alternatives to this expensive, stress-inducing, and time-consuming process, with New Zealand’s no-fault compensation system for medical errors offering a very different model of compensating patients for harms they experience².

Although just over 7% of physicians in the US have a malpractice claim filed against them every year, this ranges from nearly 20% in high-risk specialties (e.g., neurosurgery, thoracic-cardiovascular surgery) to approximately 2.6% in psychiatry³. Even though psychiatrists are among the medical specialists in the US least likely to be sued, like other physicians they have experienced a substantial increase in malpractice claims in recent years³.

A small proportion of physicians have recurrent claims, with 1% of physicians accounting for one-third of paid malpractice claims. The risk of recurrent claims is lower among psychiatrists⁴. Psychiatrists, like other physicians, are generally required by state law to carry a minimum amount of malpractice insurance, which covers the cost of defending a claim and, if necessary, of compensating an injured patient.

Data about the bases for malpractice claims in psychiatry are not compiled systematically, but most successful claims appear to involve physical injury resulting from patients’ behavior (e.g., suicidal or assaultive behavior that results in harm to the patient or to a third party) or the actions or inactions of the psychiatrist that result in physical harm (e.g., failure to monitor medication side effects leading to persistent organ-system damage). Claims based on alleged negligence in psychotherapy are much more difficult to prove and, unless they involve boundary violations by the psychiatrist – such as sexual activity with the patient – are unlikely to be successful.

Malpractice costs in the US, including the costs of settlements, judgments, legal defense, and defensive medical practices aimed at reducing the risk of malpractice claims, have been estimated at over $55.6 billion dollars annually⁵. Although this cost accounts for only a small fraction of health care spending, it is significantly higher than in other countries. Physicians win the majority of the roughly 10% of cases that proceed to trial⁴. However, since a trial is not without cost, and given the risk of losing even a strong case, malpractice insurers often choose to settle claims prior to trial, reasoning that the cost of a modest settlement may be less than the financial costs of defending the case. The cost of malpractice cases and the associated burden of defensive medical practices have led to a number of efforts to reduce the frequency of claims.

State legislators in the US have pursued a variety of approaches to reducing malpractice claims, including eliminating punitive damages, reducing the period after an injury during which claims can be brought (“statutes of limitations”), and capping the fees that attorneys can receive from such cases. The most effective laws set limits on non-economic damages that injured patients can recover, e.g., compensation for pain and suffering⁶. The variable impact of these changes in the law have stimulated medical associations and health systems to experiment with approaches outside the legal system that might reduce liability risk.

Medical associations, such as the American Psychiatric Association, have produced practice guidelines, in part as a means of reducing clinicians’ liability exposure. Practice guidelines attempt to define the parameters within which appropriate clinical care may take place, based on evidence in the relevant medical literature. They are often written so as to provide flexibility to clinicians, typically noting a variety of acceptable approaches to any clinical situation. Conformance to a generally accepted practice guideline will generally constitute a defense to malpractice claims by offering proof that the defendant-physician has complied with a professional standard of care. On the other hand, failure to comply with a practice guideline does not necessarily prove negligence; the ­physician can challenge the guidelines themselves or otherwise attempt to demonstrate that his/her behavior fell within the parameters of reasonable physician choice. As with many attempts to reduce malpractice claims, it has been difficult to demonstrate that practice guidelines have been effective for this purpose, even when systematic efforts have been made to encourage their use⁷.

A second innovative effort to reduce malpractice claims is exemplified by the approach adopted by the University of Michigan Health System⁸. When medical errors result in harm to a patient, the system encourages prompt apology by the physicians involved and an offer of payment that is usually well below what might be awarded by a court. Evaluation of the program demonstrated that it led to a reduction in the number of lawsuits, lower liability costs, and shorter time to resolution of cases. Its success may be based, at least in part, on many injured patients’ desire for an explanation of what went wrong and an apology for mistakes that were made. However, apology laws may have paradoxical effects. One recent study found that they increased the risk of malpractice suits being filed against physicians who do not perform surgery, while having no effect on surgeons’ liability risk⁹. The effect may derive from patients’ greater knowledge that an error was made, which increases motivation to seek compensation.

Given the uncertain effectiveness of legal and systemic efforts to reduce the likelihood that a physician will be subject to a claim of malpractice, the best preventive measures may rest in the hands of individual clinicians. That psychiatrists are among the least frequently sued physicians is probably due, at least in part, to the deeper and more empathic relationships they tend to have with patients. Patients who believe that their psychiatrists truly care about their well-being are less likely to sue, even if something goes wrong. In addition to maintaining a caring ­doctor-patient relationship, other pillars of prevention include seeking consultation when facing a challenging clinical situation and documenting the rationale for treatment decisions in the patient’s record, including explanations of potential management options that were not selected¹. As a general matter, doing what is best for the patient remains the surest path to reduce risk of malpractice claims.

医疗事故索赔为因医生、医院和其他医疗保健提供者的疏忽而遭受伤害的患者提供了获得经济补偿的机会。医疗事故案件中的疏忽被定义为未能遵守公认的护理标准，即，在一个常见的表述中，未能像一名合理的医生在类似情况下那样行事¹。

在美国和许多其他国家/地区，医疗事故指控在民事法庭上提起诉讼，患者原告承担证明其护理人员以疏忽方式行事的责任。近年来，人们越来越有兴趣为这种昂贵、会引起压力且耗时的过程寻找替代方案，新西兰的医疗错误无过错赔偿系统提供了一种非常不同的模式来补偿患者遭受的伤害²。

尽管美国每年有超过 7% 的医生对他们提出医疗事故索赔，但这一比例从近 20% 的高风险专科（例如神经外科、胸心血管外科）到大约 2.6% 的精神病学³不等。尽管精神科医生是美国最不可能被起诉的医学专家之一，但与其他医生一样，近年来他们的医疗事故索赔大幅增加³。

一小部分医生有经常性索赔，其中 1% 的医生占已支付医疗事故索赔的三分之一。精神科医生⁴中反复索赔的风险较低。与其他医生一样，州法律通常要求精神科医生购买最低金额的医疗事故保险，该保险涵盖为索赔辩护的费用，以及在必要时赔偿受伤患者的费用。

关于精神病学医疗事故索赔依据的数据没有系统地汇编，但大多数成功的索赔似乎涉及因患者的行为（例如，对患者或第三方造成伤害的自杀或攻击行为）或导致身体伤害的精神科医生的作为或不作为（例如，未能监测导致持续器官系统损伤的药物副作用）。基于心理治疗疏忽的指控更难证明，除非它们涉及精神科医生的边界侵犯——例如与患者发生性行为——不太可能成功。

美国的医疗事故成本，包括旨在降低医疗事故索赔风险的和解、判决、法律辩护和防御性医疗实践的成本，估计每年超过 556 亿美元⁵。虽然这笔费用只占医疗保健支出的一小部分，但它明显高于其他国家。在进行审判的大约 10% 的案件中，医生赢得了大部分⁴. 然而，由于审判并非没有成本，而且考虑到即使是一个强有力的案件也有败诉的风险，医疗事故保险公司通常选择在审判前解决索赔，理由是适度和解的成本可能低于为案件辩护的财务成本案件。医疗事故的成本和相关的防御性医疗实践的负担导致了许多减少索赔频率的努力。

美国的州立法者采取了多种方法来减少医疗事故索赔，包括取消惩罚性赔偿、缩短受伤后可以提出索赔的期限（“诉讼时效”），以及限制律师可以从中获得的费用。这样的情况。最有效的法律对受伤患者可以恢复的非经济损害设定了限制，例如对疼痛和痛苦的补偿⁶。这些法律变化的可变影响刺激了医学协会和卫生系统尝试在法律系统之外尝试可能降低责任风险的方法。

Medical associations, such as the American Psychiatric Association, have produced practice guidelines, in part as a means of reducing clinicians’ liability exposure. Practice guidelines attempt to define the parameters within which appropriate clinical care may take place, based on evidence in the relevant medical literature. They are often written so as to provide flexibility to clinicians, typically noting a variety of acceptable approaches to any clinical situation. Conformance to a generally accepted practice guideline will generally constitute a defense to malpractice claims by offering proof that the defendant-physician has complied with a professional standard of care. On the other hand, failure to comply with a practice guideline does not necessarily prove negligence; the ­physician can challenge the guidelines themselves or otherwise attempt to demonstrate that his/her behavior fell within the parameters of reasonable physician choice. As with many attempts to reduce malpractice claims, it has been difficult to demonstrate that practice guidelines have been effective for this purpose, even when systematic efforts have been made to encourage their use⁷.

A second innovative effort to reduce malpractice claims is exemplified by the approach adopted by the University of Michigan Health System⁸. When medical errors result in harm to a patient, the system encourages prompt apology by the physicians involved and an offer of payment that is usually well below what might be awarded by a court. Evaluation of the program demonstrated that it led to a reduction in the number of lawsuits, lower liability costs, and shorter time to resolution of cases. Its success may be based, at least in part, on many injured patients’ desire for an explanation of what went wrong and an apology for mistakes that were made. However, apology laws may have paradoxical effects. One recent study found that they increased the risk of malpractice suits being filed against physicians who do not perform surgery, while having no effect on surgeons’ liability risk⁹. The effect may derive from patients’ greater knowledge that an error was made, which increases motivation to seek compensation.

考虑到减少医生被指控医疗事故的可能性的法律和系统努力的有效性不确定，最好的预防措施可能掌握在个别临床医生手中。精神科医生是最不常被起诉的医生之一，这可能至少部分是由于他们与患者之间往往建立起更深入、更富有同情心的关系。相信他们的精神科医生真正关心他们健康的患者不太可能起诉，即使出现问题。除了保持关怀的医患关系外，预防的其他支柱还包括在面临具有挑战性的临床情况时寻求咨询，并在患者病历中记录治疗决定的基本原理，¹ . 一般来说，为患者做最好的事情仍然是降低医疗事故索赔风险的最可靠途径。