Closed Claims Analysis Research Articles

Why Obstetric Anesthesiologists Get Sued

Why Obstetric Anesthesiologists Get Sued

Malpractice Litigation Involving Iatrogenic Surgical Vocal Fold Paralysis: A Closed-Claims Review with Recommendations for Prevention and Management

We describe the nature of malpractice claims filed involving surgical iatrogenic vocal fold paralysis, review surgical literature for recommendations for prevention of this complication, and suggest management of this complication. Data collection was made regarding any closed claims that involved vocal fold paralysis. The results were then analyzed and categorized. The PubMed literature regarding this complication was reviewed, and recommendations on prevention were compiled. Finally, suggestions regarding management based on the current literature and the senior author's 17-year experience in his laryngeal practice are offered. From 1986 to 2007, 112 closed claims involving vocal fold paralysis were reported by the 16 largest malpractice insurers. More than US $10 million ($18 million adjusted for inflation [AJI]) has been paid thus far. The average indemnity was $285,000 ($513,000 AJI). The surgical physician defendants were from multiple specialties, including general surgery (31%), cardiothoracic surgery (12%), neurosurgery (12%), otolaryngology (10%), and orthopedic surgery (5%). The most common procedures were thyroid and parathyroid surgery (32%), cervical disc procedures (16%), thoracic procedures (12%), endarterectomy (9%), and open neck biopsy (6%). The most common claims cited were improper performance (61%), failure to recognize a complication (36%), and consent issues (19%). Vocal fold paralysis is a complication of many different surgical procedures across multiple specialty lines. Closed-claims analysis can offer a unique glimpse on what went wrong and why patients sue. Modification of techniques and incorporation of new technology may significantly reduce this complication. Preoperative written information on potential complications, and early referral to and management by laryngeal specialists, we believe, may significantly reduce malpractice litigation.

Complications Associated With Eye Blocks and Peripheral Nerve Blocks: An American Society of Anesthesiologists Closed Claims Analysis

Concern for block-related injury and liability has dissuaded many anesthesiologists from using regional anesthesia for eye and extremity surgery, despite many studies demonstrating the benefits of regional over general anesthesia. To determine injury patterns and liability associated with eye and peripheral nerve blocks, we re-examined the American Society of Anesthesiologists Closed Claims Database as part of the American Society of Regional Anesthesia and Pain Medicine's Practice Advisory on Neurologic Complications of Regional Anesthesia and Pain Medicine. Claims with eye or peripheral nerve blocks performed perioperatively from 1980 through 2000 were analyzed. The liability profile of anesthesiologists who provided both the eye block and sedation for eye surgery was compared with the profile of anesthesiologists who provided sedation only. The injury patterns associated with peripheral nerve blocks and payment factors were analyzed. Anesthesiologists who provided both the eye block and sedation for eye surgery (n = 59) had more injuries associated with block placement (P < .001), a higher proportion of claims with permanent injury (P < .05), and a higher proportion of claims with plaintiff payment (P < .05), compared with anesthesiologists who provided sedation only (n = 38). Peripheral nerve blocks (n = 159) were primarily associated with temporary injuries (56%). Local anesthetic toxicity was associated with 7 of 19 claims with death or brain damage. Performance of eye blocks by anesthesiologists significantly alters their liability profile, primarily related to permanent eye damage from block needle trauma. Though most peripheral nerve block claims are associated with temporary injuries, local anesthetic toxicity is a major cause of death or brain damage in these claims.

Challenges in Establishing the Epidemiology of Adverse Events Associated with Interventional Therapies for Chronic Pain

Objectives. This paper aims to examine the current state of knowledge about adverse events associated with interventional pain techniques. Methods. This paper reviews the available databases on risk from sources such as closed claim analysis, peer review, and published literature; and also examines risk stratification for pain practitioners, the current state of malpractice insurance, and the procedures that are considered to have elevated risk. Conclusions. Substantial neurological sequelae can occur from interventional pain techniques. Considering the growing number of physicians who perform these procedures the actual occurrence of these problems appears to be low. The incidences of complications are difficult to correctly identify based on limitations of reporting and data analysis. The author recommends a national data bank be created to allow better monitoring and self assessment of the specialty of pain medicine. This information could be used to improve outcomes, reduce risk, and change clinical practice.

An Update on Pediatric Anesthesia Liability: A Closed Claims Analysis

An Update on Pediatric Anesthesia Liability: A Closed Claims Analysis

Fatal errors in nitrous oxide delivery

Nitrous oxide continues to be used frequently and the possibility of inadvertent fatal hypoxaemia resulting from technical errors with its administration still exists. A Medline analysis revealed only a few case reports over the last 30 years, and a closed claim analysis only reported 'claims involving oxygen supply lines' predating 1990. The aim of this study was to assess the frequency of nitrous oxide-related catastrophes during general anaesthesia in Germany, Austria, and Switzerland. As nitrous oxide-related anaesthesia casualties are rare but generally prosecuted, they almost invariably attract significant media attention. We scanned mass media archives from April 2004 until October 2006 for nitrous oxide-related disasters during general anaesthesia. This approach detected six incidents which were almost certainly nitrous oxide ventilation-related deaths. Searching non-scientific data bases demonstrates that severe incidents involving oxygen supply lines occurred after 1990, and may be much more frequent than previously thought.

Comparing the Steam Engine With a Horse-Drawn Carriage?

In Response: In the study cited by Heller et al., we demonstrated similar rates of postoperative neurologic symptoms (PONS) after nerve stimulator or paresthesia techniques of nerve localization (1). Heller et al.'s negative views of paresthesia techniques are shared by many members of the anesthesia community. However, as clinicians and scientists, we should not be dealing with opinions, but rather on facts supported by rigorous scientific studies. First, Heller et al. state that the incidence of PONS in our patients is “strikingly high,” and they use a recent prospective case series (2), their “own experience,” and “European leaders' opinion” as support for this statement. “Opinions” and “experience” aside, the study referenced by Heller et al. that indicated a 3% incidence of PONS, followed patients who underwent many different operative procedures and who received either upper or lower extremity continuous peripheral nerve blockade for 2–7 days. We studied a single anesthetic and a single surgical procedure. Furthermore, in many patients, PONS presented and resolved within the timeframe of the continuous infusion referenced. Comparing these two studies is simply not appropriate. There are many more appropriate comparison studies that describe an incidence of PONS in the range we report (3–6). Second, although we agree with Heller et al. that ultrasound is a potentially useful method to assist in nerve localization for peripheral nerve block, there are few randomized, controlled trials evaluating the safety and efficacy of ultrasound in preventing PONS. Until the results of more such studies are available, we should keep an open mind. As Heller et al. correctly state, the relationship between needle tip and nerve are unclear (at best) with both paresthesia and nerve stimulator studies (7–9). In addition, a recent report by Bigeleisen (10) clearly shows that ultrasound techniques may not be reliable to avoid nerve contact. Furthermore, we do not understand the relevance of Heller et al.'s reference to the closed claims analysis (11). None of our patients suffered lasting injury, and there is no evidence that ultrasound-guided nerve blocks are safer than nerve blocks performed with other techniques. Third, Heller et al.'s comment that the volume of local anesthetic used is “outdated and potentially toxic” is another example of a commonly held, yet scientifically unsupported opinion. A comprehensive review on this topic attempts to differentiate between opinion and fact (12). Finally, it is true that it is difficult to statistically prove that two procedures yield equivalent results. We found a 9.3% incidence of PONS with the paresthesia technique (90% CI: 4.7%–13.9%) and a 10.1% incidence with the nerve stimulator technique (90% CI: 5.3%–14.7%). It is likely that if any difference did exist, it would be too small to be clinically significant. Anesthesiologists should be guided by facts supported by randomized, controlled trials, and not swayed by personal experiences and opinions. If we focus on facts, it is quite possible that other myths in anesthesia will be dispelled. We are certain that at some point during the 20th century, popular opinion was that steam engines would be the primary source of transportation energy for decades to come. Popular opinion is not always correct. Gregory A. Liguori, MD Jacques T. YaDeau, MD, PhD Victor M. Zayas, MD Richard Kahn, MD Leonardo Paroli, MD, PhD Valeria Buschiazzo, BS Department of Anesthesiology Hospital for Special Surgery Weill Medical College of Cornell University New York, New York [email protected]

Training in airway management

I have read Dr Cook's editorial [1] several times and I must confess to being somewhat disappointed. Although continuing training of both consultants and trainees is of paramount importance, it would appear that the main thrust of the editorial is orientated to the establishment of a clear airway at induction of anaesthesia. In particular, the editorial seems to focus on the use of supraglottic airways devices, particularly the laryngeal mask airway and variations thereof. There is no mention of subsequent peri-operative problems, in particular extubation of the trachea and airway problems that occur in the recovery room. Furthermore, there is no reference to the most critical aspect of management of the anaesthetised patient, which is the maintenance of adequate oxygenation at all times. A recent and very important publication in Anesthesiology[2] has been totally ignored. This article discusses the lessons that were learned from the Closed Claims Analysis of the management of the difficult airway [2]. In essence, it reported that claims following airway difficulties continue to increase. The proportion of serious claims, for example for death or brain death, in regard to induction of anaesthesia has declined (from 62% in the period 1985–92 to 35% in 1993–99). This decrease is said to reflect the introduction of difficult airway algorithms. However, the number of claims regarding difficulties during the surgical, extubation and recovery periods have remained the same. It is a matter of great concern that similar publications are unavailable in the United Kingdom and Ireland. At the very least, important lessons could be learned which could be reflected in training and future practice, thus enhancing patient safety. Difficulties during the surgical period revolve around the loss of the airway during the procedure. The reasons are several-fold but the majority seem to involve removing the supraglottic airway device and inserting a tracheal tube. I am sure that there are lessons to be learned from these experiences. The difficulties associated with extubation of the trachea vary and include patients with known difficult airways and are predominantly in those who are obese. These reasons are the same in recovery areas but, in addition, multiple attempts at re-intubation of the trachea are cited. It would seem that algorithms and strategies are of great benefit in airway management during the induction of anaesthesia. In contrast, there are no similar guidelines for the management of extubation. Furthermore, practices vary considerably [3] and some of the current practices are cause for considerable concern and, in my opinion, need to be addressed urgently. The data available about the management of patients in recovery areas seem to indicate that the majority of patients require initial upper airway assistance, such as jaw support and oxygen-enriched air therapy. There is concern as these complications should, theoretically, have decreased given the modern pharmacological agents and technological advances in airway conduits. Finally, Dr Cook's editorial does not discuss the treatment of immediate and potentially very serious complications such as laryngeal stridor. The number of patients who have a tracheal tube inserted seems to be decreasing except for those who have a tube inserted as part of a rapid sequence induction. Ironically, it is these patients who are potentially more at risk both at induction and, particularly, at extubation. It is apparent that the opportunities for training in extubation are decreasing and this decrease can, I feel, be placed at the feet of the increased use of supraglottic airway devices. How can such training be achieved? Certainly, training using mannequins is totally fruitless. What therefore are the options? I suggest that strategies and algorithms regarding extubation should be developed and published; each trainee should be required to intubate the trachea in a set number of patients during training, for example whenever neuromuscular agents are included in the anaesthetic technique (this may require curtailing the use of supraglottic airway devices); specific scenarios should be discussed at the time of extubation; each trainee should spend a period in recovery areas as they do in the USA; and each trainee should be well versed in the treatment of laryngospasm. There is an algorithm available as a guideline [4].

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Trends in Anesthesia-related Death and Brain Damage: A Closed Claims Analysis

Trends in Anesthesia-related Death and Brain Damage: A Closed Claims Analysis

Keep It Flowing: A Simulation Involving Defective Anesthetic Gas Delivery Equipment

Keep It Flowing: A Simulation Involving Defective Anesthetic Gas Delivery Equipment

An Update on Pediatric Anesthesia Liability: A Closed Claims Analysis

Respiratory complications were associated with half of pediatric malpractice claims from the 1970s to 1980s in the ASA Closed Claims Database. Advances in pediatric anesthesia practice have occurred in the 1980s and 1990s and may be reflected in liability trends. We reviewed 532 pediatric (age < or =16 yr) malpractice claims from our database over three decades (1973-2000), using logistic regression analysis to evaluate trends over time. Claims from 1990 to 2000 (1990s) were reviewed in detail to determine damaging events and injuries. Multiple logistic regression analysis evaluated factors associated with claims for death/brain damage (BD) compared with claims for less severe injuries. From 1973 to 2000, there was a decrease in the proportion of claims for death/BD (P = 0.002) and respiratory events (P < 0.001), particularly for inadequate ventilation/oxygenation (P < 0.001). However, claims for death (41%) and BD (21%) remained the dominant injuries in pediatric anesthesia claims in the 1990s. Half of the claims in 1990-2000 involved patients 3 yr or younger and one-fifth were ASA 3-5. Cardiovascular (26%) and respiratory (23%) events were the most common damaging events. Factors associated with claims for death/BD in the 1990s when compared with claims for less severe injuries were cardiovascular events (odds ratio [OR] = 6.6, 95% confidence interval [CI] = 2.5-17.8), respiratory events (OR = 3.7, 95% CI = 1.5-9.4), and ASA status 3-5 (OR = 3.1, 95% CI = 1.3-7.8). Death/BD remained the dominant injuries in pediatric anesthesia malpractice claims in the 1990s. Cardiovascular events joined respiratory events as the major sources of liability.

To See or Not to See

To See or Not to See

Analysis of surgical errors in closed malpractice claims at 4 liability insurers

The relative importance of the different factors that cause surgical error is unknown. Malpractice claim file analysis may help to identify leading causes of surgical error and identify opportunities for prevention. We retrospectively reviewed 444 closed malpractice claims, from 4 malpractice liability insurers, in which patients alleged a surgical error. Surgeon-reviewers examined the litigation file and medical record to determine whether an injury attributable to surgical error had occurred and, if so, what factors contributed. Detailed descriptive information concerning etiology and outcome was recorded. Reviewers identified surgical errors that resulted in patient injury in 258 of the 444 (58%) claims. Sixty-five percent of these cases involved significant or major injury; 23% involved death. In most cases (75%), errors occurred in intraoperative care; 25% in preoperative care; 35% in postoperative care. Thirty-one percent of the cases had errors occurring during multiple phases of care; in 62%, more than 1 clinician played a contributory role. Systems factors contributed to error in 82% of cases. The leading system factors were inexperience/lack of technical competence (41%) and communication breakdown (24%). Cases with technical errors (54%) were more likely than those without technical errors to involve errors in multiple phases of care (36% vs 24%, P = .03), multiple personnel (83% vs 63%, P < .001), lack of technical competence/knowledge (51% vs 29%, P < .001) and patient-related factors (54% vs 33%, P = .001). Systems factors play a critical role in most surgical errors, including technical errors. Closed claims analysis can help to identify priority areas for intervening to reduce errors.

ERRATUM

The American Society of Anesthesiologists has withdrawn Question #6 from the February 2006 Journal CME (Anesthesiology 2006;104:395–6). Editorial review of the related article by Bhananker et al. , entitled “Injury and Liability Associated with Monitored Anesthesia Care: A Closed Claims Analysis” (Anesthesiology 2006;104:228–34), did not yield agreement with the answers provided as possible choices. Therefore, the question is eliminated. Subscribers to February 2006 Journal CME will be given credit based on the elimination of Question #6. One credit CME will be awarded for February 2006 Journal CME as modified to five questions.

Gerard W. Ostheimer “What’s New in Obstetric Anesthesia” Lecture

Gerard W. Ostheimer “What’s New in Obstetric Anesthesia” Lecture

Instructions for Obtaining Journal CME Credit

Instructions for Obtaining Journal CME Credit

The Medical-Legal Aspects of Informed Consent in Orthopaedic Surgery

Orthopaedic surgeons routinely obtain informed consent prior to surgery. Legally adequate informed consent requires a thorough discussion of treatment options and risks and proper documentation; however, there is little data to guide orthopaedic surgeons regarding effective methods of obtaining informed consent. We performed a closed claims analysis on malpractice claims involving an allegation of inadequate informed consent brought during a twenty-four-year period with two malpractice insurers. Relevant malpractice claims were reviewed, and data were abstracted. We then performed statistical analyses to identify factors that positively correlated with a successful defense. We identified twenty-eight lawsuits that included a claim of inadequate informed consent. All of the cases involved elective orthopaedic surgical procedures; there were no emergent cases. Three cases involved a disputed surgical site; all three cases involved foot and ankle surgery and resulted in an indemnity payment. Documentation of appropriate informed consent in the office notes of the surgeon was associated with a decreased indemnity risk (p < 0.005). Obtaining the informed consent on the hospital ward or in the preoperative holding area was associated with an increased indemnity risk (p < 0.004). When informed consent was obtained in the office by the operating surgeon, the risk of malpractice payment was significantly decreased (p < 0.004). Surgeons may be able to decrease the risk of a malpractice claim by obtaining informed consent in their offices, rather than in the preoperative holding area, and by documenting the informed consent discussion within their dictated office or operative notes.

Closed Claims Analysis of 65 Medical Malpractice Cases Involving Nurse-Midwives

The threat of litigation in clinical midwifery is evident in daily practice. Although midwives have not had the same risk of claims and suits as obstetricians, all obstetric providers are potentially subject to claims of malpractice. Closed claims analysis has been used in the past to review risk patterns and to heighten awareness of certain risks. It is a methodology that can suggest corrective or preventive action for future practice and thereby minimize the risk of future errors. An analysis of nurse-midwifery closed claims can help to evaluate past risk and proactively modify future liability.

Injuries Associated with Regional Anesthesia in the 1980s and 1990s: A Closed Claims Analysis

Injuries Associated with Regional Anesthesia in the 1980s and 1990s: A Closed Claims Analysis