Anesthesia Risk Assessment

1
Anesthesia Risk Assessment Joint
Commission Issues

• Sue Cornacchio, RN, JD

2
Background American Society of
Anesthesiologists

• The first professional society for
  anesthesiologists was founded by 9 doctors in New
  York in 1905.
• In the late 1970s, ASA began to improve the
  anesthetic mortality rate by identifying the
  causes of adverse anesthesia events and
  addressing them.
• In 1985 - ASA was the first medical organization
  to create a patient safety group - the Anesthesia
  Patient Safety Foundation.
• In early 1986, ASA was the first medical
  specialty to adopt standards of care for its
  members. Today, more than 30 ASA standards,
  guidelines and statements address care of
  patients before, during and after surgery.

3
ASA Closed Claims Project

• In 1987, liability premiums were escalating and
  insurance was becoming difficult for some to
  obtain. In response, the ASA Closed Claims
  Project was started to identify major areas of
  loss and develop prevention strategies.
• ASA members continually collect case summaries
  from insurance company claim files. Most are
  from lawsuits, since litigation files contain the
  most detailed information. Currently up to 7328
  claims.
• Standardized summaries, including patient
  information, surgical procedure and positioning
  used, anesthetic evaluation and technique and the
  events leading to the claim.
• Type and severity of injury, and outcome of
  litigation are reported.
• Physicians evaluate preventability of events and
  whether standard of care was met.
• Some stipulations
• Claims can take from 6 months to 10 years to
  close. Avg. 5 yrs before entry into database.
• Dental damage claims are excluded.
• Not all injuries result in a claim. Minor injury
  claims are often dropped.
• Database favors collection of events with severe
  injuries.

4

• Damaging Events - mechanism that allegedly caused
  the injury
• Respiratory
• Cardiovascular
• Equipment
• Medication Errors
• Complications - pt. injuries allegedly caused by
  anesthesia care
• Death
• Permanent brain damage
• Nerve Injury
• Airway Trauma
• Awareness
• Burns
• Eye damage / blindness
• Trauma

5
Trends in Damaging Events

• Respiratory and Cardiovascular Events
• Primary events leading to death and brain damage
• In the 1980s respiratory more common than
  cardiovascular events
• In the 1990s respiratory and cardiovascular
  events about equal
• Respiratory events have declined substantially
• Oximetry and end-tidal CO2 monitors in use in mid
  1980s, became ASA standard in early 1990s
• Difficult Airway Guidelines introduced in 1993.
• Cardiovascular events increasing no significant
  pattern emerges.
• Injuries related to bradycardia and hypotension
  may have been incorrectly attributed to
  inadequate ventilation / oxygenation before SPO2
  and ETCO2 monitoring.
• Cheney, FW Changing Trends in Anesthesia-Related
  Death and Permanent Brain Damage ASA Newsletter
• 66(6) 6-8, 2002.

6
Damaging Events Cardiovascular Other

• Largest cardiovascular related category of events
  causing death or brain damage is unexplained
  other
• Includes pulmonary embolism, stroke, MI,
  arrhythmia and undiagnosed preop conditions such
  as cardiomyopathy identified on postmortem.
• Emerging standard ACC/AHA 2007 Guidelines on
  Perioperative Cardiovascular Evaluation and Care
  for Noncardiac Surgery
• Algorithms, clinical risk profiling to develop
  recommendations for evaluation and management of
  cardiac risk
• Overriding theme intervention is rarely
  necessary to simply to lower the risk of surgery
  unless the intervention would be indicated even
  without surgery.
• Cheney, FW Changing Trends in Anesthesia-Related
  Death and Permanent Brain Damage ASA Newsletter
  66(6) 6-8,
• 2002.

7
Damaging Events Equipment

• The third most common event associated with death
  or brain damage.
• Gas Delivery Equipment - 2 of claims in the
  1990s.
• Equipment misuse three times more common than
  equipment failure. Mainly misconnects and
  disconnects of the breathing circuit
• Most could have been prevented with use, or
  better use, of oximetry or end tidal CO2
  monitors.
• Central Venous Catheters
• High severity of patient injury, with an
  increased proportion of death compared with other
  claims in the database.
• Most common injuries were wire/catheter embolus,
  tamponade, carotid artery puncture, hemothorax,
  pneumothorax.
• Caplan RA, Vistica MF, Posner KL, Cheney FW
  Adverse Anesthetic Outcomes Arising from Gas
  Delivery Equipment
• A Closed Claims Analysis. Anesthesiology 87
  741-8, 1997.
• Domino KB, Bowdle TA, Posner KL, Spitellie PH,
  Lee LA, Cheney FW. Injuries and Liability Related
  to Central Vascular
• Catheters A Closed Claim Analysis.
  Anesthesiology. 2004 Jun100(6) 1411-1418.

8
Damaging Events Medication Errors

• Fourth most common damaging event.
• Claims related to medication errors had a higher
  proportion of permanent brain damage compared to
  other claims
• Incorrect dose most common type of error
• More common in pediatric patients
• Substitution errors second most common - involved
  syringe swaps and infusion swaps
• Muscle relaxants (succinylcholine, vecuronium),
  vasopressors and epinephrine were the most common
  accidentally administered medications.
• Succinylcholine errors can lead to intraoperative
  awareness
• Sandnes DL, Stephens LS, Posner KL, Domino KB
  Liability Associated with Medication Errors in
  Anesthesia Closed
• Claims Analysis. Anesthesiology 109 A770, 2008.

9
Complications - Trends

• Dramatic shift in injury severity over time
• Permanent disability or death from 64 in the
  1970s to 41 in the1990s
• Nerve injury and airway injury claims increasing
• Other 41 Aspirat. Pneumonia 3
• Death 23 Back pain 3
• Nerve Injury 21 Burns 3
• Brain Damage 8 MI 3
• Airway Injury 7 Newborn injury 3
• Eye Injury 5 Pneumothorax 3
• Headache 4 Stroke 3
• No injury 4 Awareness 2
• Kent, CD Liability Associated with Awareness
  During Anesthesia. ASA Newsletter 70(6) 8-10,
  2006

10
Complications Airway Trauma

• Most frequent sites of Airway Trauma
• Larynx,
• Pharynx
• Esophagus
• Can be related to difficult intubation
• Difficult intubation notation in record, letter
  to patient
• If being discharged, advise pts of sx that
  require MD follow up
• Glidescope and fiberoptic bronchoscopy now in
  wide use
• ASA Practice Guidelines for Management of the
  Difficult Airway http//www.asahq.org/publications
  AndServices/Difficult20Airway.pdf
• Domino KB, Posner KL, Caplan RA, Cheney FW
  Airway injury during anesthesia a closed claims
  analysis. Anesthesiology
• 91 1703-11, 1999.

11
Complications Nerve Injury

• Injury is usually not permanent.
• Occur with general and regional anesthesia
• Some conditions may increase vulnerability PVD,
  diabetes, ETOH, pre-existing neurologic sx
• Standard of care requires proper positioning of
  patients in OR
• Types of injury
• Ulnar nerve - most frequent
• More likely to be associated with general
  anesthesia
• More common in men
• Brachial plexus
• Lumbosacral nerve root
• More likely to be associated with regional
  anesthesia
• Spinal cord
• More likely to be associated with regional
  anesthesia
• Use of regionals at an all time high.
• Possible causes - nerves penetration during
  needle placement, neural ischemia
• Use of u/s guidance, nerve stimulation and
  specific needle tip shapes may reduce incidence
• Cheney FW, Domino KB, Caplan RA, Posner KL Nerve
  injury associated with anesthesia A closed
  claims analysis.
• Anesthesiology 90 1062-1069, 1999.

12
Complications Unintended Awareness

• Two types Claims analysis 1990 2001
• Awake paralysis
• most related to syringe swaps, almost all related
  to succinylcholine
• Recall under anesthesia
• Mechanical problems with vaporizors or vents
  causing light anesthesia
• Hypotensive pts who are unable to tolerate
  sufficient amts of anesthesia
• 25 occurred in cardiac surgery often
  hemodynamically unstable
• Difficult airway management associated with 2 of
  claims
• Women accounted for 73 of claims and only 52 of
  all other claims
• May be result of higher requirements for propofol
  and opiods.
• Increased public awareness may lead to increased
  litigation
• BIS monitors
• Medication management improvements
• Kent CD, Posner KL, Cheney FW, Lee LA, Domino KB
  Update on Closed Claims for Awareness during
  General
• Anesthesia. Anesthesiology 105 A1548, 2006.
• Kent, CD Liability Associated with Awareness
  During Anesthesia. ASA Newsletter 70(6) 8-10,
  2006

13
Complications Other

• Burns primary causes
• Cautery burns from grounding pads or cautery
  fires
• Most cautery fire burns occurred under MAC during
  plastic surgery cases, facial injury
• Warming devices cause of most lower extremity
  burns.
• Airway fires most likely to result in severe
  injury
• Laser airway fire small number of claims but
  may involve severe injury and high payment. 100
  of cases in database received payment.
• Payment was more often made in the burn claims
  than other claims. Least paid on cautery burns.
• Payment size was smaller, reflecting the lower
  severity of injury in most burn claims
• Kressin KA Burn Injury in the Operating Room A
  Closed Claims Analysis. ASA Newsletter 68(6)
  9-11, 2004

14
Complications Other

• Eye injuries
• Corneal abrasion
• Injury from movement during ophthalmic procedures
• Perioperative visual loss rare
• May be permanent, one or both eyes
• Cause unknown theories include anemia,
  intraoperative hypotension, facial edema or
  direct / indirect pressure on the eye
• Skin / soft tissue damage
• Pressure induced ischemia
• Cases that longer than 3 hours
• Prone cases
• Dental risk increases with
• Preexisting poor dentition or reconstructive work
  
• Moderately difficult to difficult intubation.
• Newland, MC. Ellis, SJ. Peters KR Simonson,JA
  Durham,TM Ullrich, FA Tinker, J Dental injury
  associated with anesthesia a report of
• 161,687 anesthetics given over 14 years Journal
  of clinical anesthesia, 65 2007.
• Gild WM, Posner KL, Caplan RA, Cheney FW Eye
  injuries associated with anesthesia.
  Anesthesiology 76204-208, 1992.

15
Special populations OB Claims

• Claims from 1990 2003 compared to claims before
  1990
• Nerve injury leading maternal injury, most
  temporary and non-disabling
• Newborn death/brain damage had decreased, yet it
  remains a leading cause of claims over time.
• Maternal nerve injury and maternal back pain
  increased
• In 1990 or later claims, anesthesia made payment
  in
• 21 of claims for newborn death/brain damage
• 60 of claims for maternal death/brain damage
• Potentially preventable anesthetic causes of
  newborn injury
• Delays in anesthesia care (anesthesia not in
  hospital for half these cases)
• Poor communication with the OB (primarily
  regarding urgency of C-section)
• Lack of emergency airway equipment or drugs in
  the labor room.
• Davies JM, Posner KL, Lee LA, Cheney FW, Domino
  KB. Liability associated with obstetric
  anesthesia a closed claims
• analysis. Anesthesiology. 2009 Jan110(1)131-9

16
Trends in Liability

• New areas of liability
• Ambulatory surgical anesthesia
• Over half of all surgeries are conducted on an
  outpatient basis
• 25 of claims in the 1990s, only 11 of claims
  in the 1980s
• Most claims for temporary and non-disabling
  injury
• Office based anesthesia
• More recent than ambulatory anesthesia, so few in
  the closed claim database
• Non-surgical pain management
• 8 of claims in the 1990s, an increase from 3
  in the 1980s
• Posner KL Closed Claims Project Shows Safety
  Evolution. APSF Newsletter 16(2) 1-3, 2001

17
Risk Management Strategies

• Policies and Procedures
• Keep updated
• Consistent with ASA Standards, Guidelines,
  Practice Advisories
• Adverse Event Reporting
• Tracking and trending
• Identify care issues between departments
• MM Conferences
• Establish review criteria
• Review cases referred by other departments
• Timely review of reportable cases

18
Joint Commission Issues

• Provision of Care surgery, moderate or deep
  sedation
• Pre-anesthesia care assessment
• Reevaluation immediately before administering
  anesthesia or sedation
• Providers qualified to administer and rescue
  patients at whatever level of anesthesia achieved
• Adequate staff present to administer, perform
  procedure and monitor pt.
• Continuous monitoring of oxygenation, ventilation
  and circulation
• IV fluids, drugs and resuscitation equipment
  available
• Evaluation and monitoring after procedure,
  including pain assessment
• Criteria for discharge from PACU

19
Joint Commission Issues

• Medication Safety
• Medications labeled whenever prepared but not
  immediately given
• Anesthesia carts
• Can be unlocked if kept in secure area
• Secure area part of larger OR that is manned at
  all times to assure constant surveillance of cart
  to prevent unauthorized access
• Scheduled drugs must be kept in locked storage
  areas
• Performance Improvement
• Data collected and analyzed
• Hospitals required to collect data on
• Operative procedures
• Adverse events related to anesthesia or moderate
  or deep sedation
• Significant medication errors
• The results of resuscitation