Classification of the risk of transmission of vaccine-preventable diseases among children under 2 years of age in the municipality of São Paulo, Brazil.

Litigation is a civil procedure that provides an avenue for individuals to contest a dispute or conflict, including negligence claims, and seek redress []. Litigation in healthcare is expressed in different ways in different countries. Hence, it is difficult to source comparable national-level data. However, incidence varies due to factors such as poverty, underdeveloped health systems, weak infrastructure, differences in legal frameworks and regulations and civil society deficits. Generally, a rise in litigation has been noted in developing countries, such as the 400% surge in recent years in India []. In developed countries, however, the incidence varies. Japan noted a decline in closed medical malpractice claims since 2006, with 13,340 closed claims between 2006 and 2021, whilst the United States of America estimated 17,000 or more claims per year []. According to the American Medical Association, in a survey of 5,825 patient care physicians, 42.2% of the physicians had a claim filed against them at some point in their careers []. The total national cost of medical errors that caused injuries was estimated to be between $17 and $29 billion per year []. These costs included disability, loss of income and healthcare expenses. Van den Bos et al. [] estimated this annual cost to be $17.1 billion in 2008. Litigation for medical negligence results from medical errors, such as diagnosis and treatment errors, improper staff supervision, the failure to communicate with patients or recognise complications, referral failure/delay, operating on the wrong patient or body part and surgical foreign body []. Hence, malpractice claims occur when a claimant, commonly a patient, 'brings a legal cause of action against his or her healthcare provider for providing (or not providing) medical treatment that falls short of the accepted medical standard of care' []. Litigation affects all stakeholders, including healthcare institutions, providers, patients and the public. Its impacts are broad, including financial impacts, integrity and confidence in the system. Regarding healthcare institutions, the New York University School of Law reported that medical errors increase average hospital costs, more so in the riskiest hospitals []. Litigation affects the patient physically, emotionally and financially. It also affects the defendant/healthcare provider emotionally and psychologically, which impacts their professional identity and integrity, giving rise to defensive medical practices. Despite the negative impact and publicity, the cases provide valuable information on demographics, nature and type of cases; case characteristics, such as reasons for lawsuits and parties involved, and case outcomes. Moreover, it provides important feedback and allows for quality assessments from the perspective of the patient and provider. Furthermore, it creates financial and political pressure to improve []. Whilst court cases are available in the public domain and case reports are also shared via bodies like the Medical Protection Society, litigation information is not always easily available, as some cases may not be highlighted or shared to avoid negative publicity. Additional challenges arise owing to the burden of proving negligence. This lies with the claimant, who often has difficulty procuring medical experts. Physicians are wary of testifying against colleagues in case their positions were to be reversed later. This is the 'phenomenon of the conspiracy of silence' []. In several developing countries, cultural practices do not reflect a litigation-oriented society, and access to justice is hampered by financial strain, long waiting periods, inadequate legal infrastructure and corruption. Few cases reach the courts. According to the National Practitioner Data Bank, from 2005 to 2009, most paid claims (96.9%) were settled outside of court, with 3.1% being judged in court []. Due to the nature of litigation and the potential for negativity, the few cases that end up in the courts are utilised to extract information to improve the healthcare system.