Equipment Problems as Damaging Events

Journal Article

  1. Mehta SP, Eisenkraft JB, Posner KL, Domino KB. Patient Injury From Gas Delivery Equipment: A Closed Claims Update. Anesthesiology 119(4): 778-795, 2013  |  NLM PubMed Link  |  Subjects: General Anesthesia, Equipment Problems as Damaging Events
    This article reviews the incidence, causes, and severity of patient injuries from anesthesia gas delivery equipment using the Closed Claims Project database from the 1970’s to the 2000’s. Over the decades, claims associated with anesthesia gas delivery equipment decreased in number and severity, with a higher proportion of awareness and pneumothorax in recent claims. These decreases are associated with advances in training and improved equipment/machine design. Eighty-five percent of recent claims were due to human error. Examples of errors were inadequate use of alarms, improvised oxygen delivery systems, and failure to initiate manual ventilation. A third of recent claims were judged preventable by preanesthesia machine check.
  2. Fitzgibbon DR, Stephens LS, Posner KL, Michna E, Rathmell JP, Pollak KA, Domino KB. Injury and liability associated with implantable devices for chronic pain. Anesthesiology 124:1384-93, 2016  |  NLM PubMed Link  |  Subjects: Pain Management, Equipment Problems as Damaging Events, Medication Errors as Damaging Events, Malpractice System, Nerve Injury
  3. Mehta SP, Bhananker SM, Posner, KL, Domino KB. Operating Room Fires: A Closed Claims Analysis. Anesthesiology 2013 May; 118(5):1133-1139  |  NLM PubMed Link  |  Subjects: General Anesthesia, Regional Anesthesia / Monitored Anesthesia Care, Equipment Problems as Damaging Events, Burns
    This study used the ASA Closed Claims Project database to assess patterns of injury and liability associated with operating room (OR) fires. Files from 1985 to 2009 were reviewed for this study. OR fires were an increasing source of injury to patients and liability for anesthesiologists. Electrocautery procedures in the presence of supplemental oxygen, especially by open delivery systems, during MAC were predominant mechanisms for OR fires. Continuing education and communication along with fire prevention protocols are crucial components to reducing the occurrence of OR fires.
  4. Bhananker SM, Liau DW, Kooner PK, Posner KL, Caplan RA, Domino KB. Liability related to peripheral venous and arterial catheterization: a closed claims analysis. Anesth Analg. 109(1):124-9, 2009.  |  NLM PubMed Link  |  Subjects: Cardiovascular System Damaging Events, Equipment Problems as Damaging Events, Physiologic Monitoring
    This analysis of claims arising from complications after peripheral IV and arterial vascular cannulation found that IV catheters were an important source of liability for anesthesiologists. IV claims involved a larger proportion of cardiac surgery procedures during which arms were tucked. Approximately half of IV claims resulted from extravasation of drugs or fluids. Claims related to radial arterial catheterization were uncommon.
  5. Domino KB, Bowdle TA, Posner KL, Spitellie PH, Lee LA, Cheney FW. Injuries and Liability Related to Central Vascular Catheters: A Closed Claims Analysis. Anesthesiology 100(6):1411-1418, 2004.  |  NLM PubMed Link  |  Subjects: Cardiovascular System Damaging Events, Equipment Problems as Damaging Events, Physiologic Monitoring
    Claims for injuries related to central vascular catheters had a greater proportion of death than other claims in the Closed Claims database. The most common central vascular catheter complications causing patient injury were wire/catheter embolus, cardiac tamponade, carotid artery puncture/cannulation, hemothorax, and pneumothorax. Patient safety may be improved by pressure waveform monitoring, use of ultrasound guidance for difficult catheterization, and checking and acting on a chest radiograph after vascular catheter insertion.
  6. Caplan RA, Vistica MF, Posner KL, Cheney FW: Adverse anesthetic outcomes arising from gas delivery equipment: A closed claims analysis. Anesthesiology 87: 741-8, 1997.  |  NLM PubMed Link  |  Subjects: General Anesthesia, Equipment Problems as Damaging Events
    Problems with equipment used in anesthesia gas delivery systems accounted for 72 (2%) of 3,791 claims in the database. The specific devices involved in these claims were the anesthesia machine, breathing circuit, supplemental oxygen delivery tubing, supply tanks or lines, vaporizors and ventilators. Misuse of equipment was more common than equipment failure, and most of these equipment problems (76%) resulted in death or brain damage. Claims associated with gas delivery equipment are infrequent but sever and continue to occur in the 1990's.

Abstract

  1. Pollak, K.A., Stephens, L., Fitzgibbon, D.R., Posner, K., Rathmell, J.P., Michna, E., Domino, K.B.: Injury and Liability associated with implantable devices for chronic pain. Anesthesiology, A1006, 2015.  |  Subjects: Professional Liability Related, Pain Management, Equipment Problems as Damaging Events, Medication Errors as Damaging Events, Nerve Injury, Quality of Care  |  PDF icon click here for pdf.pdf
  2. Herring, J.C., Posner, K.L., Domino, K.B.: Airway Injuries Associated with General Anesthesia: A Closed Claims Update. Anesthesiology, A4015, 2014  |  Subjects: Equipment Problems as Damaging Events, Respiratory System Damaging Events  |  PDF icon Click here for.pdf
  3. Esmail S, Posner KL, Stephens LS, Domino KB. Esophageal Injuries: A Closed Claims Analysis. Anesthesiology, A1081, 2012.  |  Subjects: Equipment Problems as Damaging Events, Respiratory System Damaging Events, Physiologic Monitoring  |  PDF icon esmail_esophageak_A1081.pdf
  4. Adeogba SA, Posner KL, Stephens LS, Domino KB. Central Venous Catheter Complications: Closed Claims Update. Anesthesiology, A1075, 2012.  |  Subjects: Equipment Problems as Damaging Events, Physiologic Monitoring  |  PDF icon adeogba_catheter_A1075.pdf
  5. Mehta SP, Posner KL, Domino KB. Burns from Warming Devices and Heated Materials: A Closed Claims Update. Anesthesiology, A1079, 2012.  |  Subjects: Equipment Problems as Damaging Events, Burns  |  PDF icon mehta_burns_A1079.pdf
  6. Mehta SP, Posner KL, Domino KB. Patient Injuries From Anesthesia Gas Delivery Equipment: A Closed Claims Update. Anesthesiology, A1072, 2012.  |  Subjects: General Anesthesia, Equipment Problems as Damaging Events  |  PDF icon mehta_gasdelivery_A1072.pdf
  7. Liau DW, Kooner PK, Posner KL, Cheney FW, Domino KB: Injuries and Liability Related to Peripheral Catheters: A Closed Claims Analysis. Anesthesiology 105: A945, 2006.  |  Subjects: Equipment Problems as Damaging Events  |  PDF icon Click here for .pdf
  8. Spitellie PH, Bowdle TA, Posner KL, Cheney FW, Domino KB: Injuries from Central Lines: A Closed Claims Analysis. Anesthesiology, 96: A1124, 2002.  |  Subjects: Cardiovascular System Damaging Events, Equipment Problems as Damaging Events, Physiologic Monitoring  |  PDF icon Click here for .pdf

Video/Multimedia

  1. On Patient Fires: Prevention during monitored anesthesia care (Educational Video)  |  Subjects: General Anesthesia, Regional Anesthesia / Monitored Anesthesia Care, Equipment Problems as Damaging Events, Burns  |  Full Text

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Note to Patients

These studies are primarily designed to aid physicians in improving their clinical practice. We are sorry we cannot address individual patient questions or give medical or legal advice or provide data analysis.