A trend of Medical Negligence in Laser Therapy in the Capital City: A Nine-Year Survey

Abstract

Background: the purpose of the present study is to investigate the common causes of injuries, claims, and decisions related to laser therapy medical malpractice during a nine-year survey.

Study design: This study is a retrospective descriptive study.

Methods: The legal documents in the coroner’s Office of Forensic Medicine were investigated in a national database from 2012 to 2020 in Tehran, Iran. The frequency and nature of the cases, including the year of litigation, the location and certificate of the provider, the injury sustained, the cause of legal action and judgment were collected.

Results: Three hundred and eighty-three cases related to injury from laser therapy were registered in the coroner’s Office of Forensic Medicine during the study period. The incidence of litigation related to laser surgery showed an increasing trend, with a peak occurrence in 2020.

Laser hair removal was the most common (51.2%) litigated procedure. General practice operators (48%) recorded the highest rate of laser-related medical complaints. lack of skill was the most common reason for failure. Among 383 cases with public decisions, 62.4% of them were fault liability in paid judgment.

Conclusions: Medical claims related to laser application are increasing. However, as it is clear, the growth of laser technology and the increasing demand for lasers in medical science require more surveillance to avoid probable injuries and improve patient safety, especially surveillance of the physicians who work outside the scope of their specialty.

Full text

Please cite this article as follows: Jahani- Sherafat S, Razzaghi Z, Mahdavi SA, Forouzesh M, Emam Hadi MA, Rostami-Nejad M, et al. A
trend of medical negligence in laser therapy in the capital city: a nine-year survey. J Lasers Med Sci. 2022;13:e29. doi:10.34172/jlms.2022.29.
Original Article
doi 10.34172/jlms.2022.29
A trend of Medical Negligence in Laser Therapy in
the Capital City: A Nine-Year Survey
Somayeh Jahani- Sherafat1, Zahra Razzaghi1, Seyed Amirhossein Mahdavi2, Mehdi Forouzesh2, Mohammad
Ali Emam Hadi3, Mohammad Rostami-Nejad4, Mostafa Rezaei Tavirani5, Mohammadreza Razzaghi1*
ID
1Laser Application in Medical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2Legal Medicine Research Center, Iranian Legal Medicine Organization, Tehran, Iran
3
Department of Forensic Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases,
Shahid Beheshti University of Medical Sciences, Tehran, Iran
5Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Abstract
Introduction: The purpose of the present study is to investigate the common causes of injuries,
claims, and decisions related to laser therapy medical malpractice during a nine-year survey.
Methods: The legal documents in the Coroner’s Office of Forensic Medicine were investigated in
a national database from 2012 to 2020 in Tehran, Iran. The frequency and nature of the cases,
including the year of litigation, the location and certificate of the provider, the injury sustained, and
the cause of legal action and judgment were collected.
Results: Three hundred and eighty-three cases related to injury from laser therapy were registered in
the coroner’s Office of Forensic Medicine during the study period. The incidence of litigation related
to laser surgery showed an increasing trend, with a peak occurrence in 2020. Laser hair removal
was the most common (51.2%) litigated procedure. General practice operators (48%) recorded
the highest rate of laser-related medical complaints. Lack of skill was the most common reason for
failure. Among 383 cases with public decisions, 62.4% of them were fault liability in paid judgment.
Conclusion: Medical claims related to laser application are increasing. However, as it is clear, the
growth of laser technology and the increasing demand for lasers in medical science require more
surveillance to avoid probable injuries and improve patient safety, especially surveillance of the
physicians who work outside the scope of their specialty.
Keywords: Malpractice; Laser therapy; Forensic medicine.
*Correspondence to
Mohammadreza Razzaghi, Laser
Application in Medical Sciences
Research Center, Shahid
Beheshti University of Medical
Sciences, Tehran, Iran.
Email: morazzaghi@gmail.com
Received: March 16, 2022
Accepted: June 11, 2022
Published online July 2, 2022
Journal of
Lasers
in Medical Sciences
J Lasers Med Sci 2022;13:e29
http://journals.sbmu.ac.ir/jlms
Introduction
Medical malpractice is a serious problem in any
healthcare system and causes physical and mental
harm and a financial burden on patients.1 Despite the
variation of medical litigation systems in different
countries, there are the same standards for the health
care providers.2 Four elements, including responsibility,
Violation of responsibility, causation, and harm, have
been considered for the description and survey of medical
negligence.3 According to these four elements, medical
malpractice occurs when the physician or a member of
the healthcare system takes responsibility for treating
the patient, but the function does not accord with the
standard methods.4 Studies have shown that the rate of
patients’ legal complaints in the world has been rising
recently.5 This steady rise has several reasons, including
population increase, people’s awareness of their rights,
complex technologies used in medicine, lack of proper
justification for possible side effects of remedies, patients’
increased expectations of treatment outcomes, lack of
disciplinary actions, and so on.4,6,7
Today, laser devices (‘Laser’ is the abbreviation of
Light Amplification by Stimulated Emission Radiation)
have brought about a revolution in health care systems
and are an integral part of medicine.8 Laser surgery has
increased enormously with regard to various applications
in medical or paramedical procedures in the past 2
decades, including general surgeries (e.g. gynecology,
urology, and neurosurgery), dentistry, orthopedics, and
dermatology in particular.9 Because of more attention to
beauty and aesthetics in the world, the use of lasers has
increased rapidly in the cosmetic industry.10 Furthermore,
depilation by lasers is the most popular method in
dermatology and aesthetics; removal of pigmented
lesions, tattoo removal, treatment of vascular lesions, and
facial rejuvenation are also common among several other
programs in dermatology.11
One of the advantages of laser application in surgeries
is minimal damage to tissues, resulting in diminishing
blood loss, pain, and wound infection and achieving

Jahani- Sherafat et al
Journal of Lasers in Medical Sciences Volume 13, 20222
better ulcer healing.12 However, laser surgeries are not
risk-free for human health.
Although there are strict controls on the manufacturing
and licensing of laser devices, there is a lack of
comprehensive surveillance of laser operators’ training,
physicians’ supervision, and the place where laser services
are provided, to improve patient safety.13
Therefore, given the increasing use of laser technology
in medicine, a lack of surveillance, and a rising incidence
of medical errors, related complaints in laser surgeries
are expected. In addition, medical malpractice in laser
service recipients and consequently indemnity payments
will increase. Identification and analysis of common risk
factors and errors could aid to prevent an increase in
laser-related malpractice injuries.
In Iran, medical malpractice complaints are referred to
the coroner’s Office of Forensic Medicine, in which the
patients’ complaints are checked and a decision about
negligence or innocence and financial penalties are made.
Given this, the aim of this study was to investigate the
laser-related medical malpractice data referred to the
coroner’s Office of Forensic Medicine in Tehran between
2012 and 2020 in Tehran, Iran.
Materials and Methods
Data Extraction
In this retrospective descriptive study, we readopted
the legal documents in the coroner’s Office of Forensic
Medicine in Tehran by using the keyword ‘laser’ from
2012 to 2020. Documents within this office are registered
and include legal cases, jury judgeship and summaries,
and court documents. Concerning ethical criteria, no
names including the name of the plaintiff, doctor or
medical center were included in the questionnaire survey.
Data Synthesis
This search identified 383 cases concerning injuries
resulting from laser surgery. All forensic complaint cases
that had used laser technology in the treatment process
from 2012 to 2020 were included in this study. Duplicate
files and files registered before 2012 were excluded from
the study.
Laser-medical litigation files were surveyed and
analyzed in terms of the year of action, the location,
provider’s demographic data including degrees or
certificates, as well as subspecialty practice, the nature of
the procedure including alleged injuries sustained, the
cause of action, the verdict, and indemnity payments.
The data were analyzed by descriptive statistics, using
IBM SPSS Statistics software version 24.
Results
The mean age of the plaintiffs was 37.3 ± 13.07 years and
70% of them were female. Out of 383 investigated cases,
204 (53.3 %) underwent laser therapy in private clinics,
32 (8.4%) in public hospitals, 110 (28.7%) in offices, 34
(8.9%) in private hospitals, and 3 (0.8%) in beauty salons.
228 laser treatment procedures that led to complaints
were performed by male operators (59.5%) (physician
and non-physician operators).
Figure 1 shows the increasing trend of complaints over
the given period. The highest complaints occurred in
2020 (22.19%). The dermatologic complaints were the
first reason for legal malpractice complaints each year.
Subsequently, ophthalmologic complaints were more
prevalent each year. Although there are strict controls on
the manufacturing and licensing of laser devices, there is
a lack of comprehensive surveillance of laser operators’
training, physicians’ supervision, and the place where
laser services are provided, to improve patient safety.
Table 1 shows the specialties of the operators or
supervisors of laser treatment separately for skin
treatment. The most common complaint of laser surgery
was related to 274 cases (71.5%) in dermatology, which
are listed separately from other treatments in Table 2.
The injuries and the reason for complaining about the
laser treatment procedure in these people are shown in
Table 3.
The vote of two hundred and 46 (64.2%) cases of 383
medical malpractice files was a failure and led to paid
Figure 1. Distribution of Cases by Frequency in Each Year and Medical Field.
0
10
20
30
40
50
60
70
80
90
2012 2013 2014 2015 2016 2017 2018 2019 2020
Sum of Other
Sum of Dentistry
Sum of Ophtalmology
Sum of Anesthesiology
Sum of Neurology
Sum of Surgery
Sum of Gynaecology
Sum of Dermatology
Sum of General practitioner

Journal of Lasers in Medical Sciences Volume 13, 2022 3
Medical Negligence in Laser Therapy in Tehran
indemnity, and 128 (33.4%) cases were innocence. Nine
(2.3%) forensic cases had been closed without any vote
during the present investigation.
The mean of failure in dermatological treatment
showed a high rate with 74.45% (204/274 dermatology
files), but in other fields, it showed a lower percentage;
for example, ophthalmologic legal failure included just
22.6 % (14/62 ophthalmology files) of the legal failure of
the files.
In dermatology scope, 67.15% of the failure votes were
done by general practitioners, 19.3% by dermatologists,
and 13.55% by other physicians with unrelated disciplines
(Table 1).
In the failure vote, lack of skill 153(62.2%) was the
highest reason of legal causes of action proven to be
medical malpractice, and after that, negligence 29(11.8%)
and improper treatment 64 (26%), respectively.
Discussion
In this study, we investigated the distribution and
frequency of medical malpractice related to laser
application in Tehran, Iran, between 2012 and 2020.
During this period, the Legal Medicine Organization
and Medical Council in Tehran received 383 laser-
related litigations. The distribution of cases by frequency
showed growing annual increases. Other studies showed
a growing trend of complaints about laser-related
litigation, especially in the field of dermatology and the
cosmetic industry.13 Although laser technology and laser
applications have made significant progress in medical
sciences during the last decade, it can be considered that
laser complaints have increased in accordance with total
forensic complaints in the world.10,14 Growth of patients’
awareness of their legal rights, no necessity for licenses, no
actual supervision of laser service centers, and untrained
operators could be the additional motives for increasing
complaints.13,15,16
Consistent with previous studies, more than 90% of
legal claims were made in private centers (including
offices, clinics, and hospitals). Several studies showed that
private medical centers have higher medical malpractice
in comparison with the public health system.2,15 Ong et
al compared legal claims in dermatological practice in
the National Health Service (NHS) and private centers
in England and reported that the highest percentage of
legal claims (34%) in private centers belonged to laser
treatment, whereas just 7% of legal claims in the NHS were
related to laser therapy. This result could be explained
by several considerations such as accurate supervisory
coordination in the national health system, the higher
rate of laser application in private clinics, especially in
aesthetic dermatology procedures, and lack of accurate
monitoring of operators and laser devices by specialist
supervisors.2,15 Although this must be considered,
therapeutic process charges in private centers are higher
Table 1. Subspecialty Certificates of Laser Operators and Supervisors by Skin
Treatment Scope
Physician Subspecialty Total Complaints
No. (%)
Complaints in Laser
Skin Treatment
Scope No. (% in
Each Scope)
General practitioners 183 (47.8) 184 (67.15)
Ophthalmologists 62 (16.2) 0 (0)
Dermatologists 53 (13.8) 53 (19.3)
General surgeons 25 (6.5) 2 (0.72)
Obstetrics and gynecologists 9 (2.3) 4 (1.45)
Anesthetists 9 (2.3) -
Dentists 3 (1.05) 2 (0.72)
Urologists 1 (0.3) -
Neurologists 1 (0.3) -
other 11 (2.8) 3 (1.1)
Non-physicians 26 (6.7) 26 (9.5)
Total 383 (100) 274 (100)
Table 2. Laser Procedures Performed in Forensic lawsuits
Procedures No. (%)
Hair removal 196 (51.2)
Pigment disorder 24 (6.3)
Scar 15 (3.9)
Lipolysis 15 (3.9)
Rejuvenation 13 (3.4)
Tattoo removal 12 (3.1)
Vascular 4 (1.1)
Eye disorder* 63 (16.4)
Related to pain** 18 (4.7)
Hemorrhoid 8 (2.1)
Other 15 (3.9)
Total 383 (100)
*The legal complaints related to the application of lasers in eye surgery
include cataracts, laser in situ keratomileusis (LASIK), intraocular lens
implants, etc.
**The legal complaints related to the application of lasers in pain were in
discopathy, cord spinal pain, etc.
Table 3. Injuries Sustained by the Laser Therapy Procedure
Injury No. (%)
Burns 112 (29.2)
Burns and pigmentation 57 (14.9)
Burns and scars 38 (9.9)
Pigmentation 40 (10.4)
Ulcerations 2 (0.5)
Erythema 1 (0.3)
Diminished quality of life 4 (1)
Eye and vision problems 60 (15.7)
Physical suffering 16 (4.2)
Emotional distress 11 (2.9)
Infection 8 (2.1)
Death 4 (1)
other 30 (7.8)

Jahani- Sherafat et al
Journal of Lasers in Medical Sciences Volume 13, 20224
than those in national health systems; therefore, the level
of expectations and demands in patients is higher than
that in the NHS.
One of the considerable findings in the present
study is about service providers. In this regard, general
practitioners received the highest percentage of
medical malpractice claims, and dermatologists, non-
physicians, and general surgeons are in the next ranks
(Table 1). During the last decade, litigation against practice
physicians performing cutaneous laser procedures
has shown intense growth, especially in private health
centers.17 It seems this negligence is due to financial gain
and has significant implications for the safety of patients
undergoing laser therapy. Therefore, more disciplinary
actions and supervision are essential for private clinics in
the cosmetic and skin care scope of laser therapy.
The mean age of legal claimants in the present study
was 37.3 years, but studies have shown elderly patients
have higher legal claims in comparison with young
people.18-20 This difference could be because of applicants
for laser therapy. The highest medical malpractice
claims in this investigation belonged to dermatology and
cosmetic services, and the young and middle-aged women
demanded dermatological laser therapy; therefore,
the mean age was less than total claims in medical
malpractice, although the mean age in ophthalmology
was higher than that in other fields, and these differences
refer to the target group in any medical specialty.
This study is compatible with previous studies, and it
demonstrated that the hair removal laser was the major
reason for laser-related legal claims.13,15 There has been
explosive growth in the application of hair removal
lasers since Theodore Maiman developed lasers for
destroying hair follicles in 1960.21 Now laser hair removal
is the most commonly performed laser technique in the
world.22 The highest demand for laser hair removal has
been from young females, and consequently, the highest
complications in the laser technique have been shown
in this group.23 The common side effects after laser hair
removal are superficial burns, pigmentary changes,
and scars.24,25 These complications have usually been
caused by untrained operators.23 Most laser hair removal
complications are preventable if physicians know the
skin-related side effects of procedures to correctly treat
patients and justify them for necessary care after laser
therapy. This point should be considered that laser
application to hair removal is a fast, safe, and effective
treatment if it is carried out by a physician who knows the
type of skin, probable skin-related side effects, and laser
applications.26
The death case is another noticeable point in the
current study. The causes of death for three cases who
died in this investigation have been associated with
negligence in mole removal by a laser. Mole removal
without attention to features and appearance of moles
and possibly additional tests and pathologic examination
(malignance/benign) may cause a delay in malignancy
diagnosis and treatment, leading to patients’ death.
Malignant moles are serious diseases, and the delay
in diagnosis makes a bad prognosis. Early detection
and treatment are vital for patients’ survival.27 The
ophthalmology legal claim has the second rate (16.2%) of
legal malpractice claims after the dermatology legal claim
in the current study. Laser advances in ophthalmology
are one of the most important medical applications of
lasers in medical science.28 Ophthalmology legal claims
are common cases of medico-legal complaints because
of their straight effects on a patient’s lifestyle.29 Lasers
in ophthalmology have several applications such as
laser vision surgery or LASIK [for the correction of
nearsightedness, farsightedness, or astigmatism], cataract
surgery, intraocular lens exchange, trabeculoplasty, and
so on.30-32 LASIK and cataract surgery are the first causes
of ophthalmology legal claims in the present study. As
the results showed, only 22.6% of the legal claims in the
ophthalmology section were in favor of the plaintiffs and
the acquitted.
In this survey, 9 (2.3%) of the laser-related medical
claims are about anesthesiology. Anesthesiologists in
this study used laser devices to reduce pain in the spinal
cord. Nevertheless, their activities caused a delay in
necessary surgery, leading to consequent injuries because
of a delay in treatment. Accordingly, a large number of
complaints are avoidable with correct examination and
sufficient explanation about side effects, real results, and
complications after surgery.33
Conclusion
Lack of skill and improper treatment are the two important
reasons for laser-related legal claims. Experience and
knowledge of the technical aspects of laser devices are
essential factors in the application of lasers in medical
science, so training fluent operators and monitoring their
performance are vital for utilizing lasers in medicine.
One of the important causes of medical claims refers
to no justification and perfect interaction between
physicians and patients. Raising expectations in the use
of laser devices can be one of the reasons for patients’
dissatisfaction and complaints. Physicians should explain
the risk of probabilistic subsequent complications and
possible benefits, understand patients’ concerns about
the application of lasers, and manage patient expectations
about the treatment before each decision.
Limitations of the Study
Our study has several limitations. The investigation
into patient claims was conducted within a single city.
However, we consider that laser therapy complications
are comparable in other cities in Iran. Some of the claims
were missing in the present investigation, and the non-

Journal of Lasers in Medical Sciences Volume 13, 2022 5
Medical Negligence in Laser Therapy in Tehran
medical centers like beauty salons and gyms did not
have any licenses for laser surgery and salons. Therefore,
cosmetology operators are not available and responsible,
and their legal claims were not registered in the coroner’s
Office of Forensic Medicine completely.
Acknowledgements
The authors wish to thank Dr. Ladan Jafarnejad, the Head of
the coroner’s Office of Forensic Medicine in Tehran, for her
cooperation.
Conflict of Interests
The authors declared no conflict of interest.
Ethical Considerations
The current study was approved by the local Ethics Committee of
Shahid Beheshti University of Medical Sciences (IR.SBMU.RETECH.
REC.1399.1377). To consider the ethical issue, the collected data
were not revealed to anyone except for the researchers; hence,
patients’ names were kept confidential.
Funding
The current study was financially supported by the Laser
Application in Medical Sciences Research Center, Shahid Beheshti
University of Medical Sciences, Tehran, Iran.
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