Physiologic Monitoring

Journal Article

  1. Chui J, Murkin JM, Posner KL, Domino KB. Perioperative Peripheral Nerve Injury After General Anesthesia: A Qualitative Systematic Review. Anesth Analg 2018;127:134-43  |  NLM PubMed Link  |  Subjects: Ambulatory, Offices, and Remote Locations, Professional Liability Related, General Anesthesia, Nerve Injury, Physiologic Monitoring, Quality of Care
  2. Honardar MR, Posner KL, Domino K.B. Delayed Detection of Esophageal Intubation in Anesthesia Malpractice Claims: Brief Report of a Case Series. Anesth Analg 2017;125(6):1948-51  |  NLM PubMed Link  |  Subjects: Ambulatory, Offices, and Remote Locations, General Anesthesia, Respiratory System Damaging Events, Physiologic Monitoring, Quality of Care
  3. Maxwell, B.G., Posner, K.L., Wong, J.K., Oakes, D.A., Kelly, N.E., Domino, K.B., Ramamoorthy, C.: Factors Contributing to Adverse Perioperative Events in Adults with Congenital Heart Disease: A structured analysis of cases from the Closed Claims Project. Congenit Heart Dis. 10:21-9, 2015  |  NLM PubMed Link  |  Subjects: Ambulatory, Offices, and Remote Locations, Physiologic Monitoring, Quality of Care
    This article reviews factors related to adverse events in relation to adult congenital heart disease (ACHD). Adults with ACHD are becoming a rapidly increasing proportion of the adult medical and surgical population. The authors reviewed closed medical malpractice claims from 1970 to 2001 from the Anesthesia Closed Claims Project. This article describes the contribution of perioperative risk factors to adverse outcomes as well as comparing contributing factors in cardiac versus non-cardiac operations. All cases were assessed separately for factors contributing to the adverse event and factors contributing to patient injury. Qualitative assessments are also presented and common themes across the cases reviewed.
  4. Lee, L.A., Caplan, R.A., Stephens, L.S., Posner, K.L., Terman, G.W., Voepel-Lewis, T., Domino, K.B.: Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology 122(3): 659-65, 2015. Accompanied by an editorial by Sessler D.I. Preventing respiratory depression. (Anesthesiology 122(3):484-5, 2015).  |  NLM PubMed Link  |  Subjects: Pain Management, Medication Errors as Damaging Events, Respiratory System Damaging Events, Physiologic Monitoring, Quality of Care
    This article reviews factors related to postoperative opioid-induced respiratory depression (RD). The authors reviewed closed acute pain related anesthesia malpractice claims from 1990 to 2009 from the Anesthesia Closed Claims Project. RD is a significant cause of death and brain damage, with 77% of the cases identified in this study resulting in these outcomes. Most cases occurred within 24 hours of surgery and almost all cases were deemed preventable with enhanced monitoring and response. Common risk factors were identified, including multiple prescribers, concurrent use of non-opioid sedating medications, and inadequate nursing assessment or response.
  5. Metzner J, Posner KL, Lam MS, Domino KB. Closed claims analysis. Best Pract Res Clin Anaesthesiol. 25(2):263-76, 2011.  |  NLM PubMed Link  |  Subjects: Closed Claims Project Overview, Regional Anesthesia / Monitored Anesthesia Care, Respiratory System Damaging Events, Physiologic Monitoring, Quality of Care
    The profile of anesthesia liability changed over the decades, including the types of anesthesia care associated with claims as well as events and injuries leading to claims. The most common complications in 1990-2007 were death, nerve injury and permanent brain damage. The most common anesthesia-related events leading to claims were regional-block related, respiratory, cardiovascular and equipment-related. This review includes focus on liability related to the difficult airway, monitored anesthesia care, non-operating room locations, obstetric anesthesia, and chronic pain management.
  6. Cheney FW. The American Society of Anesthesiologists closed claims project: the beginning. Anesthesiology 113(4):957-60, 2010.  |  NLM PubMed Link  |  Subjects: Closed Claims Project Overview, Regional Anesthesia / Monitored Anesthesia Care, Physiologic Monitoring
    This commentary in the Classic Papers Revisited section of Anesthesiology accompanies the reprinting of the first publication from the ASA Closed Claims Project: Unexpected cardiac arrest during spinal anesthesia: A closed claims analysis of predisposing factors by Robert A. Caplan, Richard J. Ward, Karen Posner, and Frederick W. Cheney (ANESTHESIOLOGY 1988; 68:5-11). The commentary provides the author's personal insights into the history of the ASA Closed Claims Project from its beginnings through 2010.
  7. 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.
  8. Robbertze R, Posner KL, Domino KB. Closed claims review of anesthesia for procedures outside the operating room. Current Opinion in Anesthesiology. 19(4):436-442, 2006.  |  NLM PubMed Link  |  Subjects: Ambulatory, Offices, and Remote Locations, Respiratory System Damaging Events, Physiologic Monitoring
    Nonoperating-room anesthesia claims had a higher severity of injury and more substandard care than operating room claims. Inadequate oxygenation / ventilation was the most common mechanism of injury.
  9. Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB. Trends in Anesthesia-related Death and Brain Damage: A Closed Claims Analysis. Anesthesiology 105(6):1081-1086, 2006.  |  NLM PubMed Link  |  Subjects: Respiratory System Damaging Events, Malpractice System, Physiologic Monitoring
    The significant decrease in the proportion of claims for death or permanent brain damage from 1975 through 2000 seems to be unrelated to a marked increase in the proportion of claims where pulse oximetry and end-tidal carbon dioxide monitoring were used. After the introduction and use of these monitors, there was a significant reduction in the proportion of respiratory and an increase in the proportion of cardiovascular damaging events responsible for death or permanent brain damage.
  10. 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.
  11. Tinker JH, Dull DL, Caplan RA, Ward RJ, Cheney FW: Role of monitoring devices in prevention of anesthetic mishaps: A closed claims analysis. Anesthesiology 71:541-546, 1989.  |  Abstract  |  NLM PubMed Link  |  Subjects: Physiologic Monitoring
    A review of 1,175 closed claims indicated that about one-third of the negative outcomes could have been prevented by application of additional monitors. The adverse outcomes judged preventable by additional monitoring (end tidal CO2 and pulse oximetry) are eleven times more costly than those mishaps not judged preventable.

Abstract

  1. Honardar, M.R., Posner, K.L., Domino, K.B.: Delayed detection of esophageal intubation in anesthesia malpractice claims. Anesthesiology, BOC03, 2016.  |  Subjects: Professional Liability Related, General Anesthesia, Respiratory System Damaging Events, Physiologic Monitoring, Quality of Care  |  PDF icon Click here for pdf.pdf
  2. Burden, A.R., Domino, K.B., Mincer, S.L., Posner, K.L., Steadman, R.H., Wagner, K.J., Schulz, C.M.: Situational Awareness Errors in Anesthesia Malpractice Claims. Anesthesiology, A4137, 2014  |  Subjects: Respiratory System Damaging Events, Physiologic Monitoring, Quality of Care  |  PDF icon Click here for.pdf
  3. Lee LA, Stephens LS, Caplan RC, Posner KL, Domino KD. Postoperative Respiratory Depression: A Closed Claims Analysis. Anesthesiology, A305, 2012.  |  Subjects: Pain Management, Respiratory System Damaging Events, Physiologic Monitoring  |  PDF icon Lee_postoprespdepression_A305.pdf
  4. 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
  5. 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
  6. 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

Newsletter

Closed Claims Bibliography

To access a complete bibliography of peer-reviewed journal articles from the Closed Claims Project, click here; Closed Claims Project Bibliography . You may also request delivery of the bibliography via e-mail, fax or postal mail.

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.