Respiratory System Damaging Events

Journal Article

  1. 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
  2. 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.
  3. Coté CJ, Posner KL, Domino KB.: Death or Neurologic Injury After Tonsillectomy in Children with a Focus on Obstructive Sleep Apnea: Houston, We Have a Problem! Anesth & Analg 2014 June; 118(6), 1276-83  |  NLM PubMed Link  |  Subjects: Hemorrhage, Obstructive Sleep Apnea, Respiratory System Damaging Events, Pediatrics
    This article reviews factors related to adverse events occurring during or after tonsillectomy with a focus on obstructive sleep apnea (OSA). Cases were submitted via a survey to members of the Society for Pediatric Anesthesia and review of the Anesthesia Closed Claims Project. Death or permanent neurological injury occurred in 77% of reported cases. Events occurred across the care spectrum from surgery to post-release at home. Fifty-seven percent of the children fulfilled the at risk criteria for OSA. At risk children were more likely to be obese and have co-morbidities. These are of particular concern in association with reported opioid sensitivity in children with OSA. Obesity, a history of OSA, and the use of postoperative opioids increase the risk of postoperative respiratory events. Better evaluation of these risk factors must occur, postoperative follow-up and monitoring with at risk children must be in place, and some children are not candidates for out-patient tonsillectomy.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the Difficult Airway: A Closed Claims Analysis. Anesthesiology 103(1):33-39, 2005.  |  Abstract  |  NLM PubMed Link  |  Subjects: Respiratory System Damaging Events
    Death or brain damage in claims from difficult airway management associated with induction of anesthesia but not other phases of anesthesia decreased in 1993-1999 compared with 1985-1992. Development of additional management strategies for difficult airways encountered during maintenance, emergence, or recovery from anesthesia may improve patient safety.
  9. Domino KB, Posner KL, Caplan RA, Cheney FW: Airway injury during anesthesia. A closed claims analysis. Anesthesiology 91:1703-1711, 1999.  |  NLM PubMed Link  |  Subjects: Respiratory System Damaging Events
    Claims for airway injury form a major subgroup of anesthesia malpractice claims. Perforation of the pharynx or esophagus associated with difficult intubation may result in the delayed presentation of retropharyngeal abscess or mediastinitis.
  10. Cheney FW, Posner KL, Caplan RA: Adverse respiratory events infrequently leading to malpractice suits. Anesthesiology 75:932-939, 1991.  |  NLM PubMed Link  |  Subjects: Respiratory System Damaging Events
    This report is concerned with five categories of adverse respiratory events, airway trauma (97 claims, 5% of the database), pneumothorax (67 claims, 3% of database), airway obstruction (56 claims, 3% of the database), aspiration (56 claims, 3% of the database) and bronchospasm (40 claims, 2% of the database). Airway trauma was associated with difficult intubation in 42% of the claims and the most frequent sites of injury were larynx, pharynx and esophagus. Pneumothorax was usually either needle related (block or central vascular catheter placement) or airway management related (instrumentation or barotrauma). Bronchospasm tended to occur during induction of general anesthesia in patients with a history of asthma or COPD and/or smoking.
  11. Caplan RA, Posner KL, Ward RJ, Cheney FW: Adverse respiratory events in anesthesia: A closed claims analysis. Anesthesiology 72:828-833, 1990.  |  NLM PubMed Link  |  Subjects: Respiratory System Damaging Events
    A review of 1,541 cases from the ASA Closed Claims database showed that three mechanisms of injury accounted for three-fourths of the adverse respiratory events: inadequate ventilation (196 claims; 38%), esophageal intubation (94 claims; 18%), and difficult tracheal intubation (87 claims; 17%). The esophageal intubation group was notable in that in 48% of the cases where auscultation of breath sounds were performed and documented, this test led to the erroneous conclusion that the endotracheal tube was correctly located in the trachea.

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. 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. 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
  4. 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
  5. 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
  6. Bailie R, Stephens L, Warner M, Warner M, Domino K: Liability and Risk Factors Associated with Aspiration: Closed Claims Analysis. Anesthesiology A789, 2010.  |  Subjects: Respiratory System Damaging Events  |  PDF icon Click here for .pdf
  7. Peterson GN, Posner KL, Domino KB, Lee LA, Cheney FW: Management of the Difficult Airway in Closed Malpractice Claims. Anesthesiology, 99: A1252, 2003.  |  Subjects: Respiratory System Damaging Events  |  PDF icon Click here for .pdf

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Closed Claims Bibliography

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