Leading Causes of Anesthesia-Related Liability Claims in Ambulatory Surgery Centers.

OBJECTIVE: We present a contemporary analysis of patient injury, allegations, and contributing factors of anesthesia-related closed claims, which involved cases that specifically occurred in free-standing ambulatory surgery centers (ASCs). METHODS: We examined ASC-closed claims data between 2007 and 2014 from The Doctors Company, a medical malpractice insurer. Findings were coded using the Comprehensive Risk Intelligence Tool developed by CRICO Strategies. We compared coded data from ASC claims with hospital operating room (HOR) claims, in terms of injury severity category, nature of injury, nature of allegation, contributing factors identified, and contributing comorbidities and claim value. RESULTS: Ambulatory surgery center claims were more likely to be classified as medium severity than HOR claims, more likely to involve dental damage or pain than HOR claims, but less likely to involve death or respiratory or cardiac arrest. Technical performance was the most common contributing factor: 47% of ASCs and 48% of HORs. Only 7% of allegations relating to technical performance were judged to be a direct result of poor technical performance. The most common anesthesia procedures resulting in ASC claims were injection of anesthesia into a peripheral nerve (34%) and intubation (29%). Obesity was the most common contributing comorbidity in both settings. Mean closed claim value was significantly lower for ASC than HOR claims, averaging US $87,888 versus $107,325. CONCLUSIONS: Analysis of ASC and HOR claims demonstrates significant differences and several common sources of liability. These include improving strategies for thorough screening, preoperative assessment and risk stratifying of patients, incorporating routine dental and airway assessment and documentation, diagnosing and treating perioperative pain adequately, and improving the efficacy of communication between patients and care providers.

Missed Diagnosis of Cardiovascular Disease in Outpatient General Medicine: Insights from Malpractice Claims Data.

BACKGROUND: Diagnostic errors are an underrecognized source of patient harm, and cardiovascular disease can be challenging to diagnose in the ambulatory setting. Although malpractice data can inform diagnostic error reduction efforts, no studies have examined outpatient cardiovascular malpractice cases in depth. A study was conducted to examine the characteristics of outpatient cardiovascular malpractice cases brought against general medicine practitioners. METHODS: Some 3,407 closed malpractice claims were analyzed in outpatient general medicine from CRICO Strategies' Comparative Benchmarking System database-the largest detailed database of paid and unpaid malpractice in the world-and multivariate models were created to determine the factors that predicted case outcomes. RESULTS: Among the 153 patients in cardiovascular malpractice cases for whom patient comorbidities were coded, the majority (63%) had at least one traditional cardiac risk factor, such as diabetes, tobacco use, or previous cardiovascular disease. Cardiovascular malpractice cases were more likely to involve an allegation of error in diagnosis (75% vs. 47%, p <0.0001), have high clinical severity (86% vs. 49%, p <0.0001) and result in death (75% vs. 27%, p <0.0001), as compared to noncardiovascular cases. Initial diagnoses of nonspecific chest pain and mimics of cardiovascular pain (for example, esophageal disease) were common and independently increased the likelihood of a claim resulting in a payment (p <0.01). CONCLUSION: Cardiovascular malpractice cases against outpatient general medicine physicians mostly occur in patients with conventional risk factors for coronary artery disease and are often diagnosed with common mimics of cardiovascular pain. These findings suggest that these patients may be high-yield targets for preventing diagnostic errors in the ambulatory setting.

Patient Safety in Neurosurgical Practice: Physician and Patient Factors that Contribute to Patient Injury.

BACKGROUND: Recommendations that may help reduce adverse events outside the perioperative period are uncommon. We identified the primary factors that contributed to patient injury in neurosurgical practice both within the perioperative period and outside the perioperative period. METHODS: Medical malpractice claims (n = 355) from The Doctors Company that were closed over 7 years were reviewed by neurosurgical medical experts. Objective neurosurgical expert analysis of the cases identified patient injuries and the primary factor that contributed to the patient injury. RESULTS: Continued pain, nerve damage, and need for additional surgery were the most common injuries. In 145 cases (40.8%), the primary factor that contributed to patient injury occurred outside the perioperative period: assessment (evaluation and diagnosis), selection and management of therapy, and communication between the physician and patient/family. In 138 (38.9%) cases, the primary factor that contributed to patient injury occurred within the perioperative period. Surgical complication (a known risk of the procedure) was the primary factor in 99 cases (27.9%), and technical performance of surgery was the primary factor in only 39 cases (11.0%). CONCLUSIONS: In addition to excellent surgical technique, checklists, teamwork, outcomes measurement, and regionalization of subspecialty care, improving patient safety in neurosurgical practice requires careful attention to care provided outside the perioperative period. Differential diagnosis, consideration of all relevant clinical data, active pursuit of good physician-patient relationships, and adequate monitoring of patients receiving nonsurgical treatment may also help improve patient safety in neurosurgical practice.

Analysis of patient injury based on anesthesiology closed claims data from a major malpractice insurer.

INTRODUCTION: The analysis of malpractice claims can provide risk managers with a detailed view of patient mortality and morbidity. The data comes from many institutions, encompasses a diverse group of practitioners and practice settings, and contains detailed clinical information. Analysis can help identify patterns of injury, risk factors, and rare and sentinel events. METHODS: We examined most recent anesthesia closed claims data collected by The Doctors Company, a large national malpractice insurer. We analyzed data from claims closed between 2007 and 2012. Each claim underwent a review by physician and nurse experts, and was then coded using the Comprehensive Risk Intelligence Tool. Injury distribution and association between the injury and patient comorbidity were also examined. RESULTS: A total of 607 claims were analyzed. Most frequent injuries were teeth damage (20.8%), death (18.3%), nerve damage (13.5%), organ damage (12.7%), pain (10.9%), and arrest (10.7%). Obesity was most frequently identified as a contributing factor leading to a claim. Injury-to-claim rates were highest in hospitals with fewer than 100 beds, while ambulatory surgery centers had the lowest death-to-claim rate (12%). Average indemnity for an anesthesia claim was $309 066, compared to $291 000 for all physician specialties. CONCLUSIONS: The most frequent claims were death and nerve damage when teeth damage was excluded. Obesity impacted anesthesia outcomes more frequently than did other comorbidities. Although there were fewer claims from the smaller hospitals, those claims had higher rates of mortality and nerve damage compared to larger-size hospitals. Further analysis is needed to evaluate these trends as well as impact of specific patient comorbidities on anesthesia outcomes.

Improving patient safety by understanding past experiences in day surgery and PACU.

Patient safety is a priority, yet little is understood regarding the nature of errors in the perianesthesia settings. The purpose of this claims analysis was to examine patient safety issues in the day surgery and PACU. A retrospective, exploratory design was used. Ninety-three patient safety cases were identified. Differences emerged between PACU and day surgery in regard to allegations and risk management issues. Thirty-nine percent of PACU and 25% of day surgery cases involved nurses as the primary responsible party. The top three risk management issues related to PACU nurses were clinical judgment (24%), administrative (19%), and communication (19%) issues. The top three risk management issues identified in the day surgery unit were administrative (27%), behavior-factors with patient compliance (18%), and clinical judgment issues (18%). The information gathered in this analysis can provide an impetus for units to examine their practices, organizationally and individually.