Volume 5, No. 4 • Winter 1990

ASA Closed Claims Study Tallies 8 Publications

Editor’s Note: As of November, 1990, the American Society of Anesthesiologists Closed Claim Project generated eight publications, several of which have implications for anesthesia patient safety. Presented here is a listing of the papers provided by Frederick W Cheney, M.D., Chairman of the ASA Committee on Professional Liability.

1. Caplan, R.A., Ward, R.J., Posner K., Cheney F.W.: Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology 68:5-11, 1988.

This is an in-depth review 14 cases of unexpected cardiac arrest in healthy patients winch were identified in the first 900 claims reviewed in the ASA Closed Claims Project. A major factor in the poor outcome (six deaths, eight permanent brain damage) seem to be inadequate appreciation of the need for early treatment of cardiac arrests with alpha agonists in order to counteract sympathetic blockade.

2. Caplan, R.A., Posner, K., Ward, R. J., Cheney, F.W: Peer reviewer agreement for major anesthetic mishaps. Quality Review Bulletin 14:363-368, 1988.

A study of the reliability of dosed claims reviewer judgments about standard of care, presence or absence of human error, and the role of better monitoring in the prevention of anesthetic mishaps.

Forty-two anesthesiologists reviewed 48 closed claims abstracts of anesthetic mishaps. The data demonstrated that anesthesiologists from widely different backgrounds can produce a cohesive set of judgments about anesthetic mishaps.

3. Cheney, E W, Posner, K., Caplan, R. A., Ward, R. J.: Standard of care and anesthesia liability. 1. Amer. Med. Assoc. 261:1599-1603, 1989.

The ASA Closed Claim database of 1,004 lawsuits was examined to define the impact of the “Standard of Care” as judged by practicing anesthesiologists on the likelihood on an amount of financial recovery. This paper provides a general overview of the methodology of the project. The most important finding was that if the anesthesiologist provides appropriate care there is still a greater than 40% chance that payment will be made for a claim of malpractice.

4. Tinker, J. H., Dull, D. L., Caplan, R. A., Ward, R. Cheney, E W: Role of monitoring devices in prevention of anesthetic mishaps: a closed claims analysis. Anesthesiology 71:541-546, 1989.

A review of 1, 175 closed claims indicated that about one-third or the negative outcomes could have been prevented by application of additional monitors. The adverse outcomes judged preventable by additional monitoring (end tidal C02 and pulse oximetry) are eleven times mom costly than those mishaps not judged preventable

5. Caplan, R. A., Posner, K. L., Ward, R.J., Cheney, R.W: Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology 72:828-833, 1990.

A review of 1,541 cases from the ASA Closed Claims” database showed that three mechanisms of injury accounted for three-fourths of the adverse respiratory events: inadequate ventilation (196 claims; 3 8%), esophageal incubation (94 claims; 18%), and difficult tracheal intubation (87 claims; 17%). The esophageal incubation group was notable in that in 48% of the cases where auscultation of breath sounds were performed and documented, this test led to the erroneous conclusion that the endotracheal tube was correctly located in the trachea.

6. Kroll, D.A., Caplan, R. A., Posner, K., Ward, R.J., Cheney, F. W: Now injury associated with anesthesia. Anesthesiology 73:202-207, 1990.

Of 1,541 claims reviewed, 227 (15%) were for anesthesia related nerve injury. Ulnar neuropathy represented one-third of all nerve injuries and was the most frequent nerve injury. Less frequent sites of injury were brachial plexus(23%)and the lumbosacral nerve roots (16%). Nerve damage is a significant source of anesthesia related claims but the exact mechanism of the injury is often unclear.

7. Posner K.L., Sampson, P.D., Caplan, R.A., Ward, R.J., Cheney, F W: Measuring interrater reliability among multiple raters: an example of methods for nominal data. Statistics in Medicine 9:1103-1115, 1990.

This paper describes some of the statistical refinements utilized to measure interrater reliability in the ASA Closed Claims Project.

8. Chadwick, H.S., Posner, K., Caplan, R. A., Ward, R.J., Cheney, E W: A comparison of obstetric and non-obstetric anesthesia malpractice claims. Anesthesiology. (in Press)

This is a review of 190 obstetric anesthesia claims which represent 12% of the overall 1,541 ASA Closed Claims Project Database. The most common OB claims were maternal death (22% of all OB claims), newborn brain damage (20%), and headache (12%). The group of OB claims contained a proportionally greater number of minor injuries such as headache, backache, pain during anesthesia and emotional injury (32%) compared to the non-06 claims (4%).