Quality of Care

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. Prielipp RC, Weinkauf JL, Esser TM, Thomas BJ, Warner MA: Falls From the OR or Procedure Table. Anesth Analg 125:846-51, 2017  |  NLM PubMed Link  |  Subjects: Ambulatory, Offices, and Remote Locations, Professional Liability Related, Trauma, Quality of Care
  3. Schultz CM, Burden A, Posner KL, Mincer SL, Steadman R, Wagner KJ, Domino KB. Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Analysis. Anesthesiology 2017; 127(2):326-37  |  NLM PubMed Link  |  Subjects: Damaging Event, Quality of Care
  4. 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
  5. Kent CD, Stephens LS, Posner KL, Domino KB. What Adverse Events and Injuries Are Cited in Anesthesia Malpractice Claims for Nonspine Orthopaedic Surgery? Clin Orthop Relat Res 2017;doi:10.1007/s11999-017-5303-z  |  NLM PubMed Link  |  Subjects: General Anesthesia, Regional Anesthesia / Monitored Anesthesia Care, Nerve Injury, Quality of Care
  6. Kent CD, Posner KL, Mashour GA, Mincer SL, Bruchas RR, Harvey AE, Domino KB. Patient perspectives on intraoperative awareness with explicit recall: report from a North American anaesthesia awareness registry. British Journal of Anaesthesia 2015 115 (suppl 1): i114-i121 doi: 10.1093/bja/aev211  |  NLM PubMed Link  |  Subjects: Awareness, General Anesthesia, Quality of Care
    This article, using a patient centered approach, characterizes anesthesia awareness events based on the patient’s experiences, and provides their recommendations for health care provider responses to this continuing problem. The authors reviewed self-reported incidences of recall during general anesthesia from the Anesthesia Awareness Registry. Seventy-five percent of patients were dissatisfied with the way their concerns were handled by health care providers. Problems identified by patients included lack of concern, lack of an apology, and no referrals to follow-up counselling. Patients expressed they wanted validation of their experience, explanations, and increased discussion and follow-up. Anesthesia awareness has serious impacts on some patients and more systematic responses and follow-up are needed.
  7. 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.
  8. 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.
  9. Dutton, R.P., Lee, L.A., Stephens, L.S., Posner, K.L., Davies, J.M., Domino, K.B.: Massive Hemorrhage: A report from the Anesthesia Closed Claims Project. Anesthesiology 121:450-8, 2014.  |  NLM PubMed Link  |  Subjects: Hemorrhage, Quality of Care
    This article reviews factors related to massive hemorrhage in surgical and obstetric patients. The authors reviewed closed anesthesia malpractice claims from 1995 to 2011 from the Anesthesia Closed Claims Project. Hemorrhage claims were compared to all other surgical and obstetric claims to identify recurrent patterns and medicolegal consequences. Although massive hemorrhage claims are a small proportion of surgical and obstetric claims (4%), a high percentage resulted in death or permanent injury. Compared to non-hemorrhage claims, obstetrics and thoracic or lumbar spine surgery were overrepresented, mortality was higher, care was more often judged less than appropriate, and claim payments were higher. Common risk factors and clinical problems were identified, including poor team communication, and lack of timely diagnosis, transfusion, and re-operation.
  10. 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.
  11. Lee LA, Stephens LS, Fligner CL, Posner KL, Cheney FW, Caplan RA, Domino KB. Autopsy Utilization in Medicolegal Defense of Anesthesiologists. Anesthesiology 115(4):713-717, 2011. Accompanied by an editorial by McLemore JL and Garvin AJ: Autopsy and malpractice considerations. Anesthesiology 115 (4): 685-6, 2011.  |  NLM PubMed Link  |  Subjects: Quality of Care
    Claims for deaths with evaluable autopsies were compared with deaths without autopsy from 1990 and later taken from the ASA Closed Claims Project database. Autopsy findings were helpful for the defense in 55% and harmful in 27% of the claims against anesthesiologists. Two thirds of evaluable claims indentified a significant non-anesthetic contribution to death.
  12. Metzner J, Posner KL, Domino KB. The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anaesthesiol. 22(4):502-8, 2009.  |  NLM PubMed Link  |  Subjects: Ambulatory, Offices, and Remote Locations, Respiratory System Damaging Events, Quality of Care
    This analysis of claims since 1990 compared 87 claims for anesthesia in remote locations to 3287 claims from OR procedures. Remote location claims involved older and sicker patients and utilized MAC in 50% of claims. Claims from remote locations had more severe injuries than OR claims, with a higher proportion of death and respiratory damaging events. Our data suggests that anesthesia at remote locations poses a significant risk for the patient, particularly related to oversedation and inadequate oxygenation/ventilation during monitored anesthesia care.
  13. Caplan RA, Posner K, Cheney FW: Effect of outcome on physician judgments of appropriateness of care. JAMA 265:1957-1960, 1991.  |  NLM PubMed Link  |  Subjects: Peer Review, Quality of Care
    Twenty-one cases which involved adverse anesthetic outcome were reviewed by 112 practicing anesthesiologists who were asked to judge the standard of care. Matched sets of cases were judged which differed only in outcome. A significant inverse relationship was noted between severity of outcome and appropriateness of care. For the same clinical scenario, as the severity of patient injury increased care was more apt to be judged substandard.
  14. Cheney FW, Posner K, Caplan RA, Ward RJ: Standard of care and anesthesia liability. JAMA 261:1599-1603, 1989.  |  NLM PubMed Link  |  Subjects: Closed Claims Project Overview, Quality of Care
    The ASA Closed Claims database of 1,004 lawsuits was examined to define the impact of the "Standard of Care" as judged by practicing anesthesiologists on the likelihood and amount of financial recovery. This paper provides a general overview of the methodology of the project. The most important finding was that if the anesthesiologist provides appropriate care there is still a greater than 40% chance that payment will be made for a claim of malpractice.
  15. Caplan RA, Posner K, Ward RJ, Cheney FW: Peer reviewer agreement for major anesthetic mishaps. Quality Review Bulletin 14:363-368, 1988.  |  NLM PubMed Link  |  Subjects: Peer Review, Quality of Care
    A study of the reliability of closed claims reviewer judgments about standard of care, presence or absence of human error, and the role of better monitoring in the prevention of anesthetic mishaps. Forty-two anesthesiologists reviewed 48 closed claim abstracts of anesthetic mishaps. The data demonstrated that anesthesiologists from widely different backgrounds can produce a cohesive set of judgments about anesthetic mishaps.

Newsletter

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. Douglas, R.N., Stephens, L.S., Davies, J.M., Mincer, S.L., Posner, K.L., Domino, K.B.: Communication failures in anesthesia malpractice claims. Anesthesiology, A3208, 2016.  |  Subjects: Professional Liability Related, Quality of Care  |  PDF icon click here for pdf.pdf
  3. Burden, A.R., Domino, K.B., Mincer, S., Posner, K., Steadman, R.H., Wagner, K.J., Schulz, C.: Situational awareness errors in anesthesia malpractice claims: errors of perception, comprehension and projection leading to catastrophic outcomes. Anesthesiology, A3207, 2016.  |  Subjects: Professional Liability Related, Anesthesia, Quality of Care  |  PDF icon click here for pdf.pdf
  4. Posner, K.L., Mincer S.L., Harvey A.E., Xue A.H., Van Norman G.A., Domino K.B.: Regional anesthesia decision aids in the pre-anesthesia clinic improve patient engagement and knowledge. Anesthesiology, A2211, 2015.  |  Subjects: Shared Decision-making/Informed Consent, Regional Anesthesia / Monitored Anesthesia Care, Quality of Care  |  PDF icon click here for pdf.pdf
  5. 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
  6. Metzner, J.I., Posner, K.L., Dutton, R., Domino, K.B.: Liability outside the operating room: comparison of NACOR cases with closed malpractice claims for gastroenterology, cardiology and radiology. Anesthesiology, A1009, 2015.  |  Subjects: Ambulatory, Offices, and Remote Locations, Professional Liability Related, Quality of Care  |  PDF icon click here for pdf.pdf
  7. Kutteruf, R.E., Stephens, L., Posner, K.L., Domino, K.B., Wells, D., Lee, L.: Injury and liability associated with spine surgery. Anesthesiology, A2159, 2015.  |  Subjects: Hemorrhage, Postoperative Visual Loss, Professional Liability Related, General Anesthesia, Eye Injury, Nerve Injury, Quality of Care  |  PDF icon click here for pdf.pdf
  8. Posner, K.L., Van Norman, G.A., Mincer, S.L., Harvey, A.E., Domino, K.B.: Regional Anesthesia: Patients Want Information But Most Will Leave Anesthetic Choice To Their Doctors. Anesthesiology, A1216, 2014  |  Subjects: Shared Decision-making/Informed Consent, Regional Anesthesia / Monitored Anesthesia Care, Quality of Care  |  PDF icon Click here for.pdf
  9. 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
  10. Mincer, S.L., Lee, M.J., Bransford, R.J., Adeogba, S., Posner, K.L., Chandanabhumma, P., Lam, M.S., Domino, K.B.: Shared Decision-Making (SDM) in a Surgical Clinic Setting: Adoption Through Implementation. Anesthesiology, A3035, 2013  |  Subjects: Shared Decision-making/Informed Consent, Quality of Care  |  PDF icon Click here for.pdf
  11. Twersky R, Posner KL, Domino KB: Liability in Office-Based Anesthesia: Closed Claims Analysis. Anesthesiology, A2078, 2013  |  Subjects: Regional Anesthesia / Monitored Anesthesia Care, Quality of Care  |  PDF icon Click here for.pdf

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.