Closed claims’ analysis

doi:10.1016/j.bpa.2011.02.007

Best Practice & Research Clinical Anaesthesiology

Volume 25, Issue 2, June 2011, Pages 263-276

https://doi.org/10.1016/j.bpa.2011.02.007 Get rights and content

The American Society of Anesthesiologists (ASA) Closed Claims database was started in 1985 to study anaesthesia injuries to improve patient safety, now containing 8954 claims with 5230 claims since 1990. Over the decades, claims for surgical anaesthesia decreased, while claims for acute and chronic pain management increased. In the 2000s, chronic pain management involved 18%, acute pain management 9% and obstetrical anaesthesia formed 8% of claims. Surgical anaesthesia claims with monitored anaesthesia care (MAC) increased in the 2000s to 10% of claims, while regional anaesthesia involved 19%. The most common complications were death (26%), nerve injury (22%) and permanent brain damage (9%). The most common damaging events due to anaesthesia in claims were regional-block-related (20%), respiratory (17%), cardiovascular (13%) and equipment-related events (10%). This review examines recent findings and clinical implications for injuries in management of the difficult airway, MAC, non-operating room locations, obstetric anaesthesia and chronic pain management.

Section snippets

Background

In response to rapidly rising professional liability insurance premiums during the early 1980s, the American Society of Anesthesiologists (ASA) Closed Claims Project was established in 1984 to improve patient safety and prevent anaesthetic injury.¹ At that time, anaesthesiologists were regarded as especially poor malpractice insurance risks, as 11% of total dollars paid for patient injury were anaesthetic-related complications despite anaesthesiologists accounting for only 3% of total

Strengths and limitations of closed claims analysis

Closed claims data analysis has distinct strengths and limitations that differ from other ‘outcomes’ research. One of the strengths is the ability to study a large collection of relatively rare events. Studying insurance company closed claim files is a cost-effective approach to such research, as these files contain extensive data on injuries that occurred at many different institutions and have been gathered in a centralised location. Closed claims data can be analysed as a large collection of

Trends in anaesthesia malpractice claims

Early anaesthesia claims collected by the ASA Closed Claims Project reflected mainly surgical anaesthesia care. This pattern has changed considerably over the decades. In the 1980s, for example, surgical anaesthesia represented more than 80% of all claims, while claims associated with acute and chronic pain care were relatively rare. This profile of claims changed in the 1990s, with surgical anaesthesia claims declining to 72% of all claims and chronic pain (11%) becoming as common as obstetric

Adverse events and injuries associated with management of the difficult airway

An analysis of closed claims in the management of the difficult airway revealed that difficult airways arose throughout the perioperative period: 67% on induction, 15% during surgery, 12% on extubation and 5% during recovery.²⁰ During airway emergencies, persistent intubation attempts were associated with death or permanent brain damage.²⁰ The laryngeal mask airway (LMA) was not an effective rescue technique in some claims in which multiple prolonged attempts at conventional intubation were

Conflict of interest

None.

Role of funding source

The Closed Claims Project is supported by the American Society of Anesthesiologists (Park Ridge, IL, USA). The opinions expressed herein are those of the authors and do not represent the policy of the American Society of Anesthesiologists.

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Cited by (171)

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I
2024, Revista Espanola de Anestesiologia y Reanimacion
La sección de Vía Aérea de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) y la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) presentan la Guía para el manejo integral de la vía aérea difícil en el paciente adulto. Sus principios están focalizados en el factor humano, los procesos cognitivos para la toma de decisiones en situaciones críticas y la optimización en la progresión de la aplicación de estrategias para preservar una adecuada oxigenación alveolar con el objeto de mejorar la seguridad y la calidad asistencial. El documento proporciona recomendaciones basadas en la evidencia científica actual, herramientas teórico/educativas y herramientas de implementación, fundamentalmente ayudas cognitivas, aplicables al tratamiento de la vía aérea en el campo de la anestesiología, cuidados críticos, urgencias y medicina prehospitalaria. Para ello se realizó una amplia búsqueda bibliográfica según las directrices PRISMA-R y se analizó utilizando la metodología GRADE. Las recomendaciones se formularon de acuerdo con esta metodología. Las recomendaciones de aquellas secciones con evidencia de baja calidad se basaron en la opinión de expertos mediante consenso alcanzado a través de un cuestionario Delphi.
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
Anesthesia Liability Related to Pre-existing Conditions
2024, Anesthesiology Clinics
Can intubate, but cannot extubate: A practical narrative review on extubation
2023, Trends in Anaesthesia and Critical Care
Decision and timing of removing a tracheal tube is a challenge, as extubation is a critical phase of the process that led the patient to be intubated. It is not a manoeuvre exempt of risks and morbidity, especially in critical care patients, and after neck surgery. It is essential to understand and assess the causes that may result in extubation failure to take measures that lead to success. Certain surgical procedures carry a higher risk of problems at the time of extubation. In this sense, at-risk extubation is also considered when re-intubation can be challenging. Measures should be taken to prevent and detect problems early, to optimize patient conditions prior to extubation, and to put in place strategies to deal with the potential need for re-intubation.
Reducing Risk for Perioperative Anesthesia Complications
2023, Facial Plastic Surgery Clinics of North America
Ultrasound improves percutaneous needle cricothyrotomy success in the novice anesthesia provider compared to the landmark technique
2023, Trends in Anaesthesia and Critical Care
This study tested ultrasound guidance on the success of student registered nurse anesthetists’ performance of ultrasound guided percutaneous needle cricothyrotomy versus the superficial landmark approach.
Using a quasi-experimental crossover design, students were randomized to two groups to determine order of procedural performance: (1) superficial landmark, and (2) ultrasound guided percutaneous needle cricothyrotomy. All students completed both conditions at different time points. Performance was measured using a task-specific checklist survey tool and a global rating scale. Time to successful guidewire passage and number of attempts were measured along with accuracy.
The median scores for respect for tissue, time and motion, and use of assistant categories were significantly lower when using landmark-guidance compared to ultrasound-guidance to perform the procedure (P = .021; P = .042; P = .049). Using ultrasound guidance for the percutaneous needle cricothyrotomy resulted in significantly fewer number of attempts for cricothyroidotomy access (P < .001). Post survey data indicated overall, 87.6% (CI _95%: 7.86–9.31) of the students felt the use of ultrasound improved their experience and was a valuable tool in teaching percutaneous needle cricothyroidotomy (95.9%; CI_95%: 8.56–9.77). Following the simulated experience, students felt more confident when performing the percutaneous needle cricothyrotomy procedure (87.4%; CI_95%: 1.44–3.40).
The use of ultrasound guidance during percutaneous needle cricothyrotomy showed a decrease in the number of attempts by student nurse anesthetists’ when performing cricothyrotomy. Students found ultrasound guidance enhanced the ease, speed, confidence levels, and overall experience.
Effect of 0.2% carbomer ophthalmic ointment on eye discomfort after general anesthesia: A non-randomized cohort study
2022, Revista Espanola de Anestesiologia y Reanimacion
Las lesiones oculares durante cirugía son raras. Las causas comunes incluyen trauma directo, lesión química y exposición corneal. Las molestias oculares se pueden presentar después de la cirugía en ausencia de daño estructural del ojo. En nuestro hospital todos los pacientes sometidos a anestesia general reciben protección con oclusión ocular asociado en la mayoría de los casos con la aplicación de gel oftálmico. En este estudio buscamos analizar la incidencia de molestias oculares con la aplicación de gel oftálmico de carbómero 0,2%.
Se llevó a cabo un estudio tipo cohorte. Se incluyeron los pacientes sometidos a cirugía bajo anestesia general con duración menor a cuatro horas entre febrero y noviembre de 2017. Se excluyeron a los pacientes con patologías oculares previas, los llevados a cirugía oftálmica, facial o de cabeza, y aquellos en los que la oclusión ocular no fue posible. Para el análisis, los pacientes se dividieron en dos grupos: oclusión ocular simple (Grupo 1) y oclusión ocular más gel oftálmico de carbómero al 0,2% (Grupo 2). Nuestro desenlace primario fue la incidencia de molestias oculares y el desenlace secundario fue determinar los factores de riesgo.
Se analizaron 400 pacientes, de los cuales la mitad (50%) recibieron el gel oftálmico de carbómero 0,2%. No se encontraron diferencias en las características demográficas entre grupos. Durante las primeras 24 horas postoperatorias, el 7,25% de los pacientes presentaron síntomas visuales, y a los siete días postoperatorios ningún paciente refirió síntomas. Los síntomas más frecuentes fueron visión borrosa, prurito, epífora y ojo rojo. En el análisis multivariado el principal factor de riesgo asociado con la aparición de molestias oculares fue la aplicación de gel oftálmico de carbómero 0,2% (RR 13,5; IC 95% 3,27–56,2). Otros factores asociados a molestias oculares fueron cirugía de urgencia y la edad.
La aplicación de gel oftálmico de carbómero al 0,2% no previene los síntomas oculares después de cirugía, e incluso puede aumentar el riesgo después de procedimientos cortos.
Eye lesions during surgery are rare. Its common causes include direct trauma, chemical damage, and corneal exposure. Eye discomfort may present after surgery in the absence of structural damage. In our hospital, every patient under general anesthesia receives eye protection with eye occlusion associated in most cases with ophthalmic ointment application. We aim to analyze the incidence of eye discomfort with 0.2% carbomer application.
A cohort study was conducted. Patients who underwent surgery under general anesthesia lasting less than 4 hours between February and November 2017 were enrolled. We excluded patients with previous ophthalmologic pathology, those undergoing eye, otolaryngology, face or head surgery, and patients in which eye occlusion was not possible. For analysis, patients were divided into two groups: simple eyelid occlusion (Group 1) and eyelid occlusion plus ophthalmic ointment (Group 2). Primary outcome was the incidence of eye discomfort and secondary outcomes were to stablish associated risk factors.
400 patients were analyzed, 50% were exposed to 0.2% carbomer. There was no difference in patients’ demographics. During the first 24 hours post-surgery 7.25% of patients showed visual symptoms, and at one-week postoperative no patient referred symptoms. Most frequent symptoms were blurry vision, pruritus, epiphora and red-eye. On multivariate analysis, the main risk factor associated with eye discomfort was 0.2% carbomer application (RR 13.5 CI 3.27 – 56.2). Emergent surgery and age were also found to be risk factors.
0.2% carbomer does not prevent ophthalmologic symptoms after surgery and it may even increase them in short procedures.

View all citing articles on Scopus

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14Closed claims’ analysis

Section snippets

Background

Strengths and limitations of closed claims analysis

Trends in anaesthesia malpractice claims

Adverse events and injuries associated with management of the difficult airway

Conflict of interest

Role of funding source

Anesthesiology Clinics of North America

Regional Anesthesia Pain Medicine

The American Society of Anesthesiologists Closed Claims Project: what have we learned, how has it affected practice, and how will it affect practice in the future?

Anesthesiology

Standard of care and anesthesia liability

JAMA

Claims, errors, and compensation payments in medical malpractice litigation

New England Journal of Medicine

Relation between malpractice claims and adverse events due to negligence. Results of the harvard medical practice study III

New England Journal of Medicnes

Measuring interrater reliability among multiple raters: an example of methods for nominal data

Statistics in Medicine

Effect of outcome on physician judgments of appropriateness of care

JAMA

A report by the American Society of Anesthesiologists Task Force on management of the difficult airway

Anesthesiology

Trends in anesthesia-related death and brain damage: a closed claims analysis

Anesthesiology

New trends in adverse respiratory events

ASA Newsletter

Injury and liability associated with monitored anesthesia care: a closed claims analysis

Anesthesiology

14
Closed claims’ analysis