Anesthesia in the News
  • New Study Finds One-Fifth of Anesthesia Malpractice Claims Are for Failure to Rescue

    New research presented at the European Society of Anaesthesiology and Intensive Care’s annual conference highlights the importance that failure to rescue plays in anesthesia malpractice claims with high-severity outcomes.

    The study by Karen B. Domino, MD, MPH, and her anesthesia provider colleagues at the University of Washington (UW) School of Medicine in Seattle, found that nearly 20% of claims for severe adverse events were associated with failure to rescue after postoperative patient deterioration.

    The anesthesia connection

    Failure to rescue has been described across numerous surgical specialties and is believed to be an important contributing factor to variation in mortality across U.S. hospitals, wrote Massarweh et al in Annals of Surgery (2017).

    Domino, a professor of anesthesiology and pain medicine at UW, posited that “since anesthesiologists provide postoperative management and critical care, anesthesia care may be a factor in these events.”

    To explore this premise, Domino and her team analyzed the Anesthesia Quality Institute/American Society of Anesthesiologists Anesthesia Closed Claims Project database to study clinical factors associated with postoperative deterioration which resulted in permanent disabling outcomes or death.

    Defining terms

    The researchers’ two primary inclusion criteria were:

    • patients who sustained permanent disabling outcomes or death (Injury Severity Score, 6-9) after anesthesia for surgical, obstetric, or non-OR procedures; and
    • event occurrence from 2005 or later in the database of 11,034 claims.

    Failure-to-rescue claims were defined as “deterioration events” occurring either in the Post-Anesthesia Care Unit (PACU) after the first hour of care, on the ward, or in the intensive care unit (ICU).  These events were then compared with other high-severity events occurring during all other phases of anesthesia care, which served as the study’s comparison group.

    The room where it happened

    Of 127 failure-to-rescue claims, the damaging event occurred most often in the ward (n=69, 54%), followed by in the ICU (n=39, 31%), and in the PACU (n=19, 15%).

    Compared to the comparison group (n=584), failure-to-rescue patients were sicker (ASA physical status III-V: 70% vs. 60% in the comparison group; P=0.044) and more often underwent orthopedic surgical procedures (35% vs. 25%, respectively; P=0.020).  Additionally, inadequate ventilation/oxygenation, excessive blood loss, epidural/spinal hematoma, and patient condition were more frequent damaging events in the failure-to-rescue claims

    Sex, age, obesity, emergency procedures, and severity of injury were not different between the two groups.

    “What’s interesting is that these failure-to-rescue events comprise a significant component of adverse events during anesthesia care,” Domino stated in a recent interview.  “While it may not be particularly surprising, we feel it’s unique in that these events occur outside the operating room.”

    Communicate to save

    According to the research team, the types of damaging events involved in failure-to-rescue anesthesia malpractice claims highlight the importance of timely recognition and treatment of postoperative respiratory depression, postoperative surgical bleeding, epidural/spinal hematoma and patient comorbidities to improve surgical patient safety

    “Many of these adverse events occur during handover and transfers of care to other providers,” Domino explained. “Therefore, improved communication with the surgical and postoperative teams is critical.”

    One example Domino highlights is respiratory depression, which may occur as a result of postoperative pain medication. “This is certainly something that an anesthesia professional should talk to the surgical team or hospitalist about, to remind them of that potential risk with multiple practitioners ordering pain and sedative medication.”

    The 14%

    While this study was specific to malpractice claims against anesthesiologists, it raises the question of its implication for other anesthesia providers.  Do CRNAs really get sued?  In short, yes.

    While generally, it’s the anesthesiologist named in the lawsuit, a CRNA may be named as well.  The Harvard-associated CRICO Strategies’ 2018 CBS Benchmarking Report, “Medical Malpractice in America,” analyzed 124,000 medical professional liability cases from 2007 to 2016. Although liability for nursing error-related malpractice cases tended to fall largely on organizations or physicians, the report found that individual nursing professionals — including CRNAs — were named as defendants in about 14% of those cases.

    In reviewing the CRNA statistic from the Benchmarking Report, medical malpractice liability experts at Berkshire Hathaway Specialty Insurance, noted that “Though it may seem like a small number now, it’s one that has been growing slowly over time — and one that experts fear will continue to grow as the number of malpractice claims and lawsuits increase.”

    Towards solutions

    Although the finding presented late last winter at the Euroanaesthesia conference are preliminary, Domino reports that their research continues.

    “Our plan is to query another three years of data in the Anesthesia Closed Claims [Project] database to do an in-depth analysis of the adverse events from the claim summaries,” she says.  “This qualitative analysis will help us find out why the adverse events occurred, and hopefully come up with some potential solutions.”

    “After all,” she concludes, “the ultimate goal with postoperative care is to be able to adequately treat these complications, and then rescue the patient from having an adverse event.”

    Check out Domino and colleagues’ Poster 5209 abstract, “Failure-to-rescue as a contributor to high severity outcomes in anesthesia malpractice claims,” at: https://www.esahq.org/uploads/2020/06/esa-eja-2020june-final-v2.pdf