Anesthesia in medicine has roots dating back to the mid 19th century. In fact, the first public demonstration of anesthesia is recognized as Ether Day—commemorating October 16, 1846, in Boston. But since then, many things have changed in the world of anesthesia. This includes new medication and technology development that has made anesthesia much safer. However, the safe administration and management of anesthesia have always required an important human element. As such, there is the possibility for human error and unforeseen complications—opening the door for malpractice claims. In this article, I’ll be discussing historical trends in anesthesia claims and related patient injuries.
Road to Anesthesia
To become an anesthesiologist a physician must train as a resident for four years post-medical school. After this, a physician may opt to do a fellowship for another year. This training schedule has prompted comparisons to flight training. Similar to aviation, the American Society of Anesthesiologists (ASA) promotes vigilance, constant adjustment, communication, and knowledge. Both industries also rely on technology to ensure safe results.
The ASA Database
In 1984, the ASA recognized certain serious complications during the administration of anesthesia. In response, it created the ASA Closed Claim database to address these safety concerns. The database evaluates anesthesia injuries in an effort to improve patient safety. It now contains more than 8,954 claims—with 5,230 claims since 1990.
The ASA’s Closed Claims Project reviews and analyzes closed claims files of United States professional liability insurance companies. The insurance companies participating in the project include state-wide organizations. These comprise both physician-owned and private companies, as well as companies insuring anesthesiologists in multiple states.
Per the database, claims regarding surgical anesthesia have decreased in recent years. However, claims for acute and chronic pain management have increased. It’s also important to note that anesthesia has changed dramatically over the last few decades. Namely, it has become more specialized. Subspecialties such as cardiothoracic anesthesia, regional anesthesia, ambulatory anesthesia, obstetric anesthesia, critical care, pain medicine, and pediatric anesthesia have all developed to maturity in recent decades. Each subspecialty comes with its own benefits, risks, and complications for patient treatment. This proliferation of specialized approaches can help us understand how anesthesia has become safer, but not risk-free.
Examining Claims Trends
The below chart illustrates the areas of anesthesia responsible for the most claims during the 2000s 1 3 :
During the 2000s, surgical anesthesia claims with monitored anesthesia care (MAC) increased to 10% of claims. MAC describes when patients undergo local anesthesia along with sedation and analgesia. Further, regional anesthesia rose to 19% of claims.
Also during this period, the most common serious complications associated with any type of anesthesia were:
The most common damaging events due to anesthesia in claims were:
Other reports have shown similar numbers. The most frequent injuries reported were 2 :
Claims Changes Over Time
According to the database, death is the leading outcome in anesthesia claims between 1990-2007. Nerve injury accounted for 22% of claims. Two-thirds of these injuries were temporary and non-disabling. The remaining one-third were permanent and disabling. Further, airway injury accounted for 7% of injuries.
But in the last two decades, claims for MAC (monitored anesthesia care) anesthesia, acute, and chronic pain have increased significantly. According to the most recent report from the Society for Ambulatory Anesthesia (SAMBA), more than two-thirds of surgical procedures in the U.S are done in surgical centers and medical offices. In many cases, MAC is the preferred technique for these procedures.
In the 1980s, MAC claims represented 2% of claims—this figure has risen to 10% in 2000 and after. Although the use of airway instrumentation is minimal at most, and the amount of anesthetic is usually much less in a MAC technique. Death was more common with MAC techniques than in general or regional anesthesia. One possible explanation is that MAC may provide a false sense of safety to anesthesia providers, thereby, increasing the possibility of negative outcomes.
On the other hand, the amount of regional anesthesia claims has not changed over time, accounting for nearly 20–25% of claims in each decade. However, the introduction of ultrasound-guided regional anesthesia (USGRA) may have caused a decline in recent claims. This technique has slowly become the standard of care over the last seven years.
Individual Complications
Another way to examine trending anesthesia claims is to separate out each different complication. This highlights which events and steps of anesthetic care are linked to different injury types.
Airway Care
Teeth damage is the most common non-threatening complication in anesthesia (20.8%). Injuries to the teeth are most commonly associated with airway care during general anesthesia. On the other hand, difficulties with a patient’s airway are one of the most feared and serious complications faced by anesthesiologists. They carry a possibility of death or permanent brain damage. Difficult airways were encountered on induction in 67% of cases, during surgery in 15% of cases, on extubation in 12%, and in 5% of cases during recovery. It is important to mention that death and permanent brain damage from difficult intubation at induction of anesthesia has declined since the adoption of ASA practice guidelines.
MAC Anesthesia
During MAC anesthesia, the airway is not protected. However, potent medications are given to keep the patient comfortable during the procedures. It is not surprising then that medication overdose by anesthesiologists was the most common mechanism of injury. It accounts for 21% of MAC claims. Over half of over sedation cases involved combinations of propofol and benzodiazepines or opioids (such as versed and fentanyl).
Advanced age, obesity, and performing a procedure in a remote location were other involved risk factors. The database indicates substandard care in the majority of cases. It also found that many injuries were preventable. Key areas for improvement were better monitoring, including pulse oximetry, end-tidal capnography, or both. Burn injuries are also more common during MAC than general or regional anesthesia. Fires accounted for nearly a fifth of MAC claims and were more common during surgery on the head, face, and neck. Clinicians utilized an electrocautery tool with supplemental oxygen in all burn cases. In these cases, nasal cannulas, face masks, or face tents supplied the oxygen.
Obstetric Anesthesia
Newborn death/brain damage still constitutes a large number of claims (21%). Maternal nerve injuries (21%) are also prevalent. These are largely temporary and non-disabling. Severe disabling spinal cord injuries occurred in 10% of nerve injury claims due to direct spinal cord injury, epidural hematoma, abscess, or anterior spinal artery syndrome.
Management of Chronic Pain
Malpractice claims for chronic pain medication involved mostly young men with chronic back pain (53%). These patients were primarily treated with opioid analgesics (94%). Fatal outcome was highly prevalent in these scenarios, accounting for nearly 60% of claims. the primary cause of death in over 60% of claims was the use of long-acting opioids, such as oxycodone and methadone alone or in conjunction with other psychoactive medications. Chronic pain management presents a challenge to physicians due to the patient population served, the use of invasive techniques, and the prescription of very strong medications. Analysis has shown that two intertwined major factors contributed to 82% of claims: patient non-compliance with the treatment, and/or substandard care provided by the physician.
Closing Thoughts
Anesthesia has become safer over time, but it is still not without risks. Every single anesthesia subspecialty strives to provide the best and safest patient care. The use of potent medications, in combination with invasive procedures to protect the airway and provide pain relief, has inherent risks that anesthesiologists must face every day in their clinical practice.
1) Closed claims analysis. Metzner J, Posner KL, Lam MS, Domino KB. Best Pract Res Clin Anaesthesiol. 2011 Jun; 25(2):263-76.
2) Analysis of patient injury based on anesthesiology closed claims data from a major malpractice insurer. Ranum D et al. J Healthc Risk Manag.2014
3) http://depts.washington.edu/asaccp/projects/anesthesia-closed-claims-project
