Closed Claims Study Seeks Data

B Robert J. Ward, M.D.

Improved patient safety! Such a noble goal rnust be in the very heart of every conscientious anesthesiologist-but how? It is only by knowing where the problems are that any concerted effort can be made to master them, and therein hangs the major obstacle to beginning the attack

The American Society of Anesthesiologists has initiated a massive review of closed claims against anesthesiologists, as found in the files of IS of the physician-owned insurance companies and of the St. Paul Fire and Marine Company. Acting through its Professional Liability Committee, chaired by Frederick W. Cheney, Jr., M.D., a practicing anesthesiologist will review each dosed claim in the individual state’s files, extracting the data of importance to the clinician. The data will be collated by Richard J. Ward, M.D., a member of the Committee, and used by the Society in its many teaching activities

This project, like so many dynamic ones, had its start in the minds of several persons, whom chance brought together at the auspicious moment. An attorney friend (later the wife) of Richard Solazzi, M.D., suggested that considerable data on anesthetic malpractice problems could be found in the files of the insurance companies. Dr. Solazzi, then a resident in Anesthesiology at the University of Washington, suggested to Dr. Ward that they review the files of the Aetna Insurance Company to ascertain which clinical problems led to malpractice suits. The two reviewed a decade’s experience in Washington State in the files of the Aetna Insurance Company, of the King County Medical Examiner, and of the two largest hospital systems, Group Health and the University of Washington. At the same time on the opposite coast, Ellison C. Pierce, Jr., M.D., was editing a book on anesthesia mishaps. The Washington state data was included in the book, but much more importantly, stirred the officers of the ASA to pursue a national survey, large enough to identify the common and not so common clinical problems that caused patient injury

Changes in the insurance coverage suggested that it would be best to approach the physician-owned insurance companies, and the St. Paul fire and Marine Company. The cooperation of the insurance companies has been outstanding, as it was with the Aetna Insurance Company in the original survey. To date 432 cases have been reviewed, and a preliminary estimate suggests that over 1000 may be available for review when the program is finished.

The program is unique in several ways. It is, by far, the largest review of anesthesia complications, and the resultant

malpractice suits, in America. Secondly, by having practicing anesthesiologists do the reviewing, it allows professional judgments to be made about many of the aspects of clinical care. Judgments are being made in several areas, such as: was the recorded preanesthesia evaluation adequate, would better preanesthetic evaluation probably have prevented the complications, would currently available monitors have prevented the complication (even though they were not available at the time of the complication), was the anesthesia care adequate or inadequate, could the anesthetic have caused the complication, was the treatment adequate if there was a cardiac arrest, and who was responsible for the complication (even though not preventable).

These professional judgments offer unique strength to the survey, and allow it to go far beyond the usual survey details, i.e., general or regional anesthesia administered, the type of complication noted, and the cost of any judgment. The identification of both preventable and non-preventable complications, and their causes, point the way to the proper targets of the ASA’s educational programs for physicians. These targets have, to date, remained elusive, but they are now being identified.

As an example, of the 432 suits reviewed there were 29 patients who had an unrecognized esophageal intubation that caused the patient to die or have brain damage. Eighteen of these patients had bilateral auscultation of the chest. While it was surprising to note the comparatively high frequency of this complication, it was much more so to note that bilateral auscultation of the chest so frequently failed in making the diagnosis.

The efficacy of pulse oximetry and end tidal carbon dioxide analysis has been demonstrated in the findings to date. In a subset of 156 cases, it was estimated that these monitors, especially pulse oximetry, would have prevented 20% of the complications. This 20% represented almost 60% of the payments, $13,000,000 of the total of $24,000,000.

The costs of inadequate care are equally well demonstrated. ‘Mere is no way that we can quantify the depth of the personal tragedy of severe complications or death, but we can quantify the dollar costs. The average settlement when the care was adjudged adequate was $88,597, while it jumped to $220,953 when the care was considered to be inadequate.

The primary goal of the study is to improve patient safety, by identifying the complications that occur during routine clinical anesthesia, and then developing study programs to communicate the findings to the clinicians. Recognizing that the study group may be a skewed population (although a growing number of complications seem to be followed by a suit), two derivative studies are being contemplated. Working with the Society of Academic Anesthesia Chairmen, a parallel study may be made compiling the clinical complications reported in the weekly mortality and morbidity conferences of a large number of training programs. The other would be a compilation of the data available from anesthetic deaths reviewed by participating medical examiners of the country. Almost half of the medical examiners said that they reviewed all or most of the anesthetic deaths reported to them. further, they feel that they hear about most of the anesthetic deaths in their comrnunity. These facts came from a survey of the members of the National Association of Medical Examiners by Drs. Richard J. Ward and Donald Reay, the King County, Washington, Medical Exarniner. Thus, a large number of anesthetic deaths are already being reviewed by the medical examiners, and a national survey of these could, and should, be made.

Data are being shared with the participating insurance companies who request it, and they will likewise work on improving patient safety in ways that they find most effective.

Dr. Ward is Professor of anesthesia, University of Washington School of Medicine, Seattle.