Circulation 118,032 • Volume 29, No. 3 • February 2015   Issue PDF

Obstructive Sleep Apnea Death and Near Miss Registry Opens

Karen L. Posner, PhD; Norman Bolden, MD

The Obstructive Sleep Apnea (OSA) Death and Near Miss Registry opened in May 2014 and is now accepting case reports. The goal of this new registry is to identify recurring patterns or themes underlying death or adverse events suspected to be related to obstructive sleep apnea with an ultimate aim of risk prevention and improved anesthesia patient safety. The Registry seeks to obtain a large number of case reports to achieve these goals.

OSA or sleep-disordered breathing is present or suspected in many patients presenting for anesthesia care. Patients with OSA are at risk for difficult airway management and opioid-induced respiratory depression. The postoperative risks may extend for a number of days as regular sleep patterns are re-established. The American Society of Anesthesiologists Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea recommend screening of patients with characteristics associated with OSA in advance of their procedure so an appropriate perioperative management plan can be developed.1 Screening does not provide a diagnosis, and anesthesia professionals continue to face challenges in developing perioperative plans weighing risks and benefits of perioperative care choices for patients with signs or symptoms of OSA but lacking a definitive diagnosis. Transfers of care postoperatively present additional challenges in providing appropriate continuity of care for these patients, adding the risk of perioperative care plans falling through the cracks as patients are transferred to unmonitored settings or discharged to home.

Some initial cases submitted to the OSA Registry exemplify the complexity of perioperative management of OSA patients. In one case of a patient diagnosed with OSA preoperatively, the patient’s CPAP was not used postoperatively, continuous monitoring was not in place, and signs of respiratory depression were missed by the floor nurse. In another case the patient’s history of OSA was assessed by the anesthesia provider, who developed an appropriate perioperative care plan. With a change in shift postoperatively, the patient’s OSA history was overlooked, pain management protocols were changed, and continuous monitoring discontinued. The patient was found non-responsive less than 1 hour after the last nursing check. Both of these OSA-related adverse events occurred on the night following the surgical procedure.

These cases illustrate themes in perioperative risks for OSA patients related to patient management and monitoring that, while perhaps obvious to many, were clearly not obvious to all of the health care professionals involved in the care of these patients. A broad sample of adverse events will create opportunities to identify additional risks in patient identification and management that may drive initiatives to prevent such adverse events in the future.

The OSA Death and Near Miss Registry is the culmination of a multi-year planning process started by a committee of the Society for Anesthesia and Sleep Medicine (SASM). The current SASM OSA Death and Near Miss Registry Committee includes Norman Bolden, MD (chair), Dennis Auckley, MD, Kenneth Bachenberg, MD, Jonathan Benumof, MD, Frances Chung, MBBS, David Hillman, MD, Frank Overdyk, MD, Satya Krishna Ramachandran, MD, and David Samuels, MD. The Anesthesia Closed Claims Project and its Registries, part of the Anesthesia Quality Institute (AQI), has teamed with the SASM committee to implement the Registry, provide technical assistance, and serve as a repository for Registry data. The Anesthesia Closed Claims Project will also serve as a source of Registry case reports obtained through collection of closed anesthesiologist malpractice claims throughout the United States. Karen L. Posner, PhD, and Karen B. Domino, MD, MPH, are leading the effort on behalf of the Anesthesia Closed Claims Project/AQI. The project offices are currently housed at the Department of Anesthesiology and Pain Medicine at the University of Washington in Seattle.

The case report form includes significant clinical detail. Due to its length and complexity, and data confidentiality concerns, electronic case reports are not an option at this time. Case report instructions and forms are available on the OSA Death and Near Miss Registry website:

Cases must meet specific inclusion criteria:

  1. Patient age 18 years or older at time of event
  2. Event occurred in 1993 or later
  3. Patient was diagnosed or suspected to have OSA (before or after the event)
  4. One of the following events suspected to be related to OSA must have occurred within 30 days of surgery:
  • Unanticipated death suspected to be related to OSA
  • Brain injury (diagnosed by a neurologist) suspected to be related to an adverse event related to OSA
  • Event or outcome suspected to be related to OSA:
    • Urgent/Emergent transfer to ICU from general ward due to respiratory distress
    • Respiratory arrest (prolonged apnea not responsive to vigorous stimulation)
    • Code Blue or ACLS protocol

Case reports do not contain identifiers for patients, providers, or institutions, so they represent anonymous data. In order to protect anonymity, case reports are not linked to their source. No link is maintained between individual case reports and the person submitting the report, in order to further protect the confidentiality of the case report system and those generously sharing their cases with this project. Questions about case submission and confidentiality should be directed to Dr. Posner at
[email protected] or by telephone at (206) 616-2630.

Karen L. Posner, PhD, is a Research Professor, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.

Norman Bolden, MD, is an Associate Professor, Case Western Reserve University, Department of Anesthesia, MetroHealth Medical Center. Cleveland, OH.

Disclosure: The authors have no financial conflicts in relation to the content of this article.


  1. American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: An updated report by the American Society of Anesthesiologists task force on perioperative management of patients with obstructive sleep apnea. Anesthesiology 2014; 120 (2):268-86.