Transcript TIPS - Alaska Association of Nurse Anesthetists

Medical-Legal Issues:
Staying In the OR
and Out of Court
Lynn Fitzgerald Macksey
RN MSN CRNA
Anesthesia…and Medical Malpractice
“For some must watch
while some may sleep….”
- Shakespeare
2
Anesthesia…and Medical Malpractice
 How attorneys think about you, your
practice, and how to win against you
during lawsuits.
**examples of cases
**tips and techniques
TIPS
3
MEDICAL MALPRACTICE CASES
 Criminal
Usually not for medical cases unless it’s
a crime against society
 Punishment includes incarceration and
punitive damages

 Civil

Tort Law
Medical malpractice / negligence
4
MEDICAL MALPRACTICE CASES
Civil Disputes
Arise when plaintiffs (patients) believe they
have been unfavorably affected by the
actions of another, the defendant (CRNA)—
and so seek judicial relief, that is, a courtroom
judgment.
5
“Captain of the Ship”
 Surgeon liable for any
errors in the OR.
 This, however, has
changed.
 Each caregiver can
now be named in
a medical malpractice
suit and is responsible
for his/her own actions.
6
Elements of Negligence
 Four Elements of Medical Malpractice
1.
2.
3.
4.
Duty
Breach of duty, i.e., negligence
Causal connection
Injuries/Damages
Without all four of these,
negligence cannot be proven.
7
#1 Duty
 It is a relationship between the healthcare
provider and the patient – when care has
started or anytime a patient needs help.
 If there is no duty…there is no case.
8
#2 Negligence – breach of duty
 Negligence is the failure to do that which is
consistent with good and acceptable
practice… the “Standard of Care”.
 What is reasonable and prudent?
9
Who decides negligence…
or standard of care?
 A qualified expert witness speaks to the
standard of care.
 Opinions are expressed in degrees of
likelihood.
10
Negligence
 Negligence occurred if the plaintiff can prove
the CRNAs care fell below the Standard of
Care.
 The plaintiffs must then prove they were
injured as a direct result of the CRNAs
negligence….this is known as causation.
11
#3 Causation
 A causal connection must be established
between the breach of duty and the injury or
harm to the patient / plaintiff.
 Who determines causation?
 Expert witness: nurse, physician,
pathologist, toxicologist, etc.
12
Causation
 In a anesthesia med-mal case, one of the
experts jobs is to identify the role of each
provider involved in the case.
 Including actions which may have
contributed to adverse outcomes ~~ and
actions which may have prevented or
reduced injury.
WHAT DID YOU DO TO PROTECT THE PATIENT?!
13
Causation
Causation is the attorney’s most
important element in any
malpractice case.
14
Causation Principles
 The forseeability issue: was it foreseeable
that a particular act could cause harm or
damage?
 The CRNA has a responsibility to foresee
harm and eliminate risks.
 Ex:
medication errors, nerve damage
15
Causation Principles
 “But For The” negligence issue: that is the
injury that would not have occurred
“but for a particular act”.
 The expert witness will attempt to explain that,
if it hadn’t been for the conduct of the
defendant, the patient would not have been
injured.
16
Causation Principles
 Causation is more difficult to prove than duty
or breach of duty.
 Even though the patient may have an obvious
injury, the cause of the injury may not be
clear.
 This is where the defense focuses.
 The defense will suggest other causes for the
injury, only one of which may have been the
CRNA’s negligence.
17
Causation Principles
 Because causation can be so difficult to prove, the
court allows plaintiffs to argue their case using the
theory of res ipsa loquitur -
“The thing speaks for itself.”
#1: the injury must be of a type that would not
ordinarily occur unless someone were
negligent.
#2: the defendant had exclusive control over
whatever caused the plaintiff’s injury.
#3: the injury could not have resulted from
anything the plaintiff voluntarily did.
18
Causation Principles
 When res ipsa loquitur is used, the plaintiff is
allowed to prove negligence by presenting
only circumstantial evidence.
 This is opposite from most malpractice cases -
ordinarily, the court presumes the defendant
used ordinary care until the plaintiff proves
otherwise.
19
#4 Damages
 Plaintiffs must show they suffered some type
of damage and because of the injury, they
are entitled to monetary compensation.
The plaintiff’s attorney has the burden of proof.
20
Damages claimed
 Financial

Medical costs, wage loss…
 Physical
Disfigurement
 Loss of sensation: hearing, touch, smell…
 Loss of consortium

 Mental

Pain, anguish, loss of joy…
 Includes past and future loss
21
No case is black and white!
 The bottom line?

Does the attorney think they can win?
 Are
 Is
all of the elements present?
the patient credible?
 Are
the damages sufficient to justify the
expense and time required to prosecute a
case?
22
Does the case have merit?
 Most attorneys want to see a major physical
injury or a loss of earning capacity before they
take on a case.
 Look at the degree and extent of the injury.
 Has full recovery been made?
 What is the short and long term prognosis?
23
Does the case have merit?
Is the
outcome
someone’s
fault?
Doesn’t always
matter.
24
Paramedics
25
L&D Nurse
Verdict: $9 million
26
Wrong Leg, Right?
1995, instead of having
his right foot removed,
a Florida diabetic man
had his left leg cut off
below the knee .
In the end, the proper foot
also had to be
amputated and the
patient was left with no
legs.
Verdict: $1 million
27
Screwed, to Say the Least
When the surgeon could
not find the necessary
titanium rods required
for patient back surgery,
the surgeon removed
the handle from a
nearby screwdriver and
used it instead.
Verdict: $5.6 million
28
Left Brain, Right Brain
In 2007, it was discovered
that doctors at a Rhode
Island hospital had
performed brain surgery
on the wrong side of their
patient’s brain… on three
different patients.
The second incident
prompted the state to
enforce greater oversight
among their
neurosurgeons.
The third “wrong side of the
brain” incident occurred
three months later.
29
Dr. Feelbad
An Ohio doctor was arrested in
1988 for experimenting in a
series of reconstructive
vaginal procedures on
female patients without their
consent.
Upon his arrest, it was
discovered that the doctor
had been undertaking these
procedures for 22 years, on
over 2000 women.
Verdict information unavailable
30
Not as Easy as Chopping
Broccoli
In 1998, Saturday Night Live
alum Dana Carvey,
underwent a double bypass
heart operation to address
recurring heart problems.
Postoperatively, the star found
that his chest pains
continued.
It was in a follow-up
appointment that Carvey
realized that his surgeon had
bypassed the wrong
coronary artery.
Verdict: $7.5 million
31
It all sounds so obvious…
32
Production pressure
 Unwritten organizational factors
in the anesthesia and surgery environment
may exacerbate human error.
 “Production pressure” may cause adverse
outcomes as cost constraints affect clinical
practice.
 Include such things as  inadequate preoperative evaluation
 necessary monitors not being used.
33
Are you adequately prepared?
 In a 1991 case, an attending MDA and an
anesthesiology resident were found to have
failed to have a sufficiently small endotracheal
tube on hand during hip surgery on a 5-month
old child. Unsuccessful intubation attempts were
alleged to have continued for an inordinately long
period.
 The child suffered severe hypoxia causing a
persistent vegetative state.
 Verdict: $9 million
34
Production pressure
 Legal verdicts increasingly address
“premature extubation” as an important
plaintiff’s allegation in cases where
postextubation respiratory compromise
results in traumatic reintubation, awareness,
or hypoxemia.
 Recent premature extubation verdicts in
Michigan and Virginia have ranged form
$450,000 to $700,000.
35
Production pressure
How can we meet
production expectations while
minimizing patient safety and
professional liability risks ** Maintaining safe
practice guidelines.
** Increased communication between ALL
providers involved in a patient’s care.
Production pressure?
 A 40-year-old male died of a cardiopulmonary
arrest during a surgical biopsy procedure
when the anesthetist performed a premature
extubation of the patient.
 The plaintiff contended that the defendant
hospital was negligent in failing to have a
twitch monitor present during the procedure.
Verdict: $2 million
37
Production pressure?
 A case involving premature extubation that
also alleged the intraoperative administration
of excessive fluid, leading to severe facial
edema resulted in multi-million dollar verdict
on behalf of an 8-year-old child.
 The jury formed the opinion that the MDA
should have known the extubation was not
safe under those circumstances.
38
Fast-tracking
 A set of anesthesia techniques aimed at
speeding recovery from anesthesia and
improving outcomes, with the overall goal of
reducing health costs.
 Inappropriate use of or overaggressive fast-
tracking actually reduces the quality of patient
care and increases liability.
39
If something can go wrong......
 In general, 1 fatality occurs in every 500 medical
encounters.
 An almost perfect medical process (99.9%) in an
average community hospital would still result in
accidents, such as:
* 15 retained instruments,
* 17 transfusion reactions, or
* 1,000 medication delivery errors…
annually!!
40
Anesthesia Malpractice Data
Closed Claims Data
 Closed Claims are medical malpractice
claims related to significant anesthesiarelated patient injuries and demand of
payment made by injured parties or their
representatives.
 this data is evaluated in-depth to determine
relationships between
 treatment,
 injuries sustained, and
 the basis of lawsuits.
41
Closed Claim Data
 1985
 ASA
started the Closed Claim Project
 2001
 the
AANA published their findings
regarding CRNAs involved in closed
claims.
42
Closed Claim data
 This data has led to
higher standards of care
and mandatory
monitoring.
43
Closed Claim Data
 Using this information can help to
improve clinical practice
 evaluate new therapies
 anticipate problems

44
Closed Claim Data
 Medical malpractice is not only based on
medical malpractice or negligence, but other
issues such as  lack
of informed consent,
 treatment beyond scope of consent,
 assault and battery, and
 abandonment.
45
Closed Claim Data
 Overall injury rate in US hospitals ~4%
 1 in 8 injured patients file claims
 The #1 type of patient to sue:
* healthy adults
* undergoing routine elective surgery
* females > males
* 50% of claims involve obese patients
46
Closed Claim Data
$34 to $32 million
http://depts.washington.edu/asaccp/sites/default/files/pdf/Click%20here%20for%20_12.pdf
47
Closed Claim Data –
top 3 reasons lawsuits are filed
#1 lawsuit: (29%)
death
#2 lawsuit: (19%)
peripheral nerve damage
#3 lawsuit: (9%)
brain damage
48
Other reasons suits are filed
 Central Venous Catheter placement (16.5%)
 Low risk incidences (15%)
 Emotional damage, headache, pain during
regional anesthesia and back pain after
neuraxial anesthesia.
 Misuse or failure of equipment (10%)
 Burns (6%)
49
Other reasons suits are filed
 Wrong drug dose (4%)
 Eye injury (3%)
 Recall / Awareness (2%)
50
Death or Brain damage
Death or brain damage
was precipitated by
respiratory events (45%)
and
cardiovascular events (25%)
51
Undisclosed settlement
in child’s death
A 6-year-old child received general anesthesia for a
dental restoration procedure. His only history was mild
asthma.
 After extubation, the child’s oxygen saturation
dropped quickly; he became diaphoretic and
lethargic. CRNA had the circulator get a fan to blow
over the child to cool him off. The child coded.
 The child’s autopsy showed hemorrhagic changes to
the lungs with no heart abnormality.
 Experts concluded the child had a unrecognized
laryngospasm.
Verdict: case still in review
J. Hill, Virginia; 2010
52
Verdict Against CRNA for
anoxic brain injury
20 year old female undergoing MAC sedation for
cervical surgery in an ambulatory surgery center.
CRNA administered deep sedation causing respiratory
and cardiac arrest resulting in anoxic brain injury.
 The patient had sickle-cell disease which was not
gleaned from preoperative interview.
 Patient had also taken pain medication the morning
of surgery which was not known to the CRNA.
Verdict: $851,000
53
Respiratory Events
 Adverse outcomes associated with
respiratory events are the single largest class
of serious injury in the ASA Closed Claims
Study.
54
Respiratory Events
 Two-thirds of adverse respiratory events are
due to:
inadequate ventilation (38%),
 esophageal intubation (18%), and
 difficult tracheal intubation (17%)

 Inadequate ventilation was characterized by
the highest proportion of cases in which
care was considered substandard (90%).
55
Inadequate ventilation
A 41-year-old female having outpatient surgery
for carpal tunnel syndrome died after she
suffered an acute hypoxic and hypotensive
episode during sedation anesthesia.
 The defendants denied negligence and
contended that being a smoker was the
proximate cause of decedent's death.
Verdict Award: $0
BARNA, ESTATE OF v. HACKENSACKTOWN COMMUNITY HOSPITAL; BODNER, M.D.; MURPHY, M.D.; ET. AL
56
Improper intubation
Wrongful death to decedent who died after
being comatose for 3 years.
 Anesthesiologist unable to properly intubate
decedent during toe amputation surgery
which resulted in lack of oxygen, cardiac
arrest and subsequent comatose condition.
Verdict: $1,742,000
JOHNSON, v. P.A.S.
57
Morbidly obese 72-year-old
male for Afib ablation
1205 - Extubated at end of case, tongue noted to be swollen,
sats 89% on arrival to PACU. Facemask on 10 liter flow.
1253 - coughing up bloody secretions, right neck and tongue
grossly swollen. Sats dropping, multiple physicians called
and consulted.
1425 – Pt now unable to speak, sats 82% - to OR for
emergency trach. Multiple attempts at intubation; (same)
MDA tried multiple times for cricothyrotomy. General
surgeon in another OR and unaware of this patient.
1437 - General surgeon pulled out of another surgery and
emergency trach done.
Sats between 20-70% for 24 minutes.
Postoperatively, patient is unresponsive to all stimuli and dies
several days later.
Lucas; 2011
58
Verdict: case still in review
Respiratory events
 Airway trauma
Larynx (33%)
 Pharynx (19%)
 Esophagus (18%)
 Trachea (14%)
 Temporomandibular joint [TMJ] (10%)

59
Airway trauma
In an Oregon case, a woman with prior TMJ
problems underwent general endotracheal
anesthesia for tonsillectomy.
 Postoperatively, she developed disability
associated with the TMJ – she claimed she
was not told of risks of endotracheal
intubation in light of her condition.
Settlement of $350,000
Lonnie Smith Sexton v. Kaiser Foundation Hospitals, Oregon; 1993
60
Airway trauma
A 40-year-old female suffered perforation of
the upper airway, resulting in swallowing
problems, during an endotracheal intubation.
She later developed a mediastinal abscess.
 The plaintiff
alleged
the defendant
made
defendant
maintained
the plaintiff's
several unsuccessful
intubation
attempts
swallowing
problems were
psychological,
using
excessive
force because
of improper
unrelated
to intubation,
that appropriate
equipment.was used, and that possibility of a
equipment
perforation is a known risk of the procedure.
Verdict: $0
UECK v. BAIDYA, M.D.
61
Respiratory events
 Aspiration
 Aspiration
occurs primarily during induction
but can also occur anytime intraoperatively,
postoperatively, and during all types of
anesthesia; i.e.: regional or sedation
anesthesia.
 Large
percentage of these patients have
associated brain damage and/or death.
62
Aspiration
A sixty-four year-old woman required general
anesthesia for incarcerated ventral hernia. She
aspirated gastric contents at induction and died one
month later.
 The plaintiff alleged that the CRNA failed to take
extra precautions for the patient’s conditions
(obesity, symptoms of bowel obstruction, narcotic
medication) which all increased the risk of
aspiration.
No mention of cricoid pressure in this case.
Verdict: $210,000
In BB v. BW, CRNA, Kanabec County, Minnesota; 1994
63
Aspiration
 In another case of a patient who aspirated
stomach acids during induction of anesthesia and
died.
 The blame was on the anesthesiologist who did
not apply cricoid pressure during induction of
anesthesia, despite a history of gastric reflux and
obesity. This case was decided based on cricoid pressure.
Verdict: $966,000
Luellen Makeny v. Parisian M.D.
64
Respiratory events
Difficult airway management during
perioperative period occurs
Induction 67%
 Surgery 15%
 Extubation 12%
 Recovery 6%

65
Respiratory events
During surgery a 30-year-old female died from
cerebral anoxia after undergoing a cesarean
section and elective tubal ligation.
 Surgeon noticed dark red blood; patient had
an unrecognized right mainstem intubation.
Verdict: $837,600
FOSTER, ESTATE OF v. CHOI, M.D.
66
Respiratory events
In a 2008 case, an 11month-old infant
undergoing surgery to
remove a superfluous digit
experienced profound
hypoxic encephalopathy.
The episode occurred
during induction after LMA
insertion but the MDA
could not ventilate.
Verdict: $2 million
67
Respiratory events
Difficult airway
algorithm –
do you know it?
68
Respiratory events
In 2002, the family of a 61-year-old woman who
died sued the anesthesiologist.
 The woman had been extubated following a
hysterectomy, requiring an emergent
tracheotomy, which was subsequently
dislodged in the ICU causing hypoxia, cardiac
arrest, and death.
Verdict: $2.2 million
69
Respiratory events
 Difficult
original intubation (4 attempts)
with swelling of throat
 Trendelenburg
 Known
position for 7 hours
laryngeal polyps
 Morbidly
obese patient with a large neck
70
Respiratory events
 Difficult Airway

intraoperatively:
Death 46%
 Difficult Airway

outside the OR
Death 87%
71
Respiratory events
All adverse respiratory events in PACU
are found to be preventable with the
use of continuous pulse oximetry.
72
Are you adequately prepared?
Remember this case?
 An attending and a resident were found guilty
and had to pay $9 million dollars for failing to
have a sufficiently small ETT on hand for a 5month old who now is in a persistent vegetative
state.
73
Anesthesia Equipment & Monitors
TIPS:
 All emergency equipment ready…
whether giving GETA, regional, neuraxial,
sedation or out-of-department procedures.
 ALWAYS!!!! Suction on and ready, Bougie,
ambu available, oral airways, blades and
handles, OETT ready to go.
 Preformulated reintubation plan.
74
Anesthesia monitors & alarms
 A 44-yr old female having left ankle surgery.
She had been disconnected from the ventilator
to turn from the supine to the prone position.
The circuit was then reconnected and the vent
was turned on BUT the ventilator did not
start and alarms had been turned off.
 The patient suffered anoxic encephalopathy
and permanent brain damage after being
apneic for ~ 8 minutes.
Verdict: $12 million
75
Anesthesia Equipment & Monitors
TIPS:
Monitors and alarms are invaluable, particularly
end-tidal carbon dioxide detectors, pulse
oximeters, train-of-four monitors, oxygen
analyzers, and ventilator disconnect alarms.
76
Anesthesia Equipment & Monitors
 Misuse of equipment

3x more likely than equipment failure
 Mis/disconnects
of breathing circuit largest
contributor to patient injury
 Equipment failure
77
Anesthesia Equipment & Monitors
TIPS:
 Reviewers judged that over half of the claims
(53%) of equipment misuse or failure could
have been prevented by pulse oximetry,
capnography, or a combination of these two
monitors.

Constant vigilance

Proper equipment check before using
78
Anesthesia Equipment & Monitors
TIPS:
 Check all anesthesia equipment to confirm
good operation at start of each day.
 Adhere to all institutional safety precautions
to minimize the risk of injury.
79
Anesthetic Plan
TIPS:
Formulate a patient-specific anesthetic plan and
discuss with the patient.
Document plan discussion.
80
Informed Consent
 Informed Consent was problematic in 1% of
closed claims
 Anesthetic plan and possible complications
not explained
 Failed to discuss a change in anesthesia
plan with the patient.
 Provider failed to honor a patient request
 i.e.: no medical student involved
81
Informed Consent
TIPS:
 Discuss the anesthetic plan and make sure you
understand what your patient expects regarding the
anesthetic.
 Discuss and document Do Not Resuscitate orders.
 Do not go against patient wishes regarding students in
the OR.
82
Informed Consent
TIPS:
 Patients should understand that no anesthetic
technique is risk-free.
 Protecting yourself comes down to
DOCUMENTATION.
83
Preanesthetic Assessment
 A cursory review of a patient’s history can lead
to patient harm and medical malpractice.
 In one emergency case, a patient required
emergency surgery for left hemothorax. The
patient had several serious medical problems,
including a very recent cardiopulmonary
arrest.
 The CRNA only received an oral report
preoperatively from the anesthesiologist.
84
Preanesthetic Assessment
 Remember the patient with sickle cell who
had taken pain medicine that morning….

Would it have changed your anesthetic if you
had known about the chronic disease and the
preoperative opioid?

What questions could you have asked to help
glean this information from the patient?
85
Preanesthetic Assessment
TIPS:
A thorough preoperative assessment is
mandatory and leads to appropriate planning
to reduce the chance for difficulties during
anesthesia care….you cannot reduce risk to
zero but will minimize any catastrophe.
Documentation of preanesthetic evaluation
is essential.
86
Preanesthetic Assessment
TIPS:
Preexisting Conditions
Know what the condition of the patient is in
when you begin care – has patient already
experienced trauma? has a neuro deficit?
teeth missing?...
…anything that has not
been documented…
chart it!
87
Preanesthetic Assessment
TIPS:
Complete and thorough assessment including  Medical and surgical history
 Previous anesthetics
 Current medications
 Cardiac status: METS score
 Respiratory/Pulmonary status
 etc….
88
Respiratory - perioperative
TIPS:
 Good preoperative airway assessment
 Have all emergency airway equipment available for
any suspect airways…ambu, Bougie, oral airways,
laryngeal mask airways.
 Be intimately familiar with Difficult Airway Algorhythm.
 Continuously monitor capnography and oxygen
saturation.
 Alert, timely recognition of respiratory emergencies &
action saves lives.
89
Respiratory - intubation
TIPS:
 Make your first look your best look with
intubation.
 Known difficult airway? Surgeon should be
readily available to perform a surgical airway
if needed.
90
Respiratory - intubation
 For any difficult or esophageal intubation,
alert the surgeon and the patient to watch
for –
early signs (pneumothorax and subQ
emphysema)
late signs (mediastinitis or retropharyngeal
abscess).
 Letter to patient?
91
Respiratory - monitoring
Before capnographyit took > 5 minutes to confirm correct placement
of endotracheal tube.
With capnographyconfirmation occurs within seconds
and death / brain damage
from esophageal intubation
↓ from 11% to 3% of claims.
92
Respiratory - monitoring
TIPS:
Use
Capnography monitoring
along with
Pulse ox monitoring
93
Respiratory - monitoring
 One study demonstrates that 72% of negative
respiratory outcomes could have been
prevented by combined oximetry with
capnography monitoring….so use both
monitors whenever possible.
Preventable injuries are 11x costlier
in medical-malpractice cases.
94
Aspiration of gastric contents
TIPS:
 In aspiration risk cases, analysis should focus
on risk identification and reduction.
 Patients who are at extra risk for aspiration of
gastric contents require special preparation
with preoperative medication and choice of
anesthetic techniques.

i.e.: if patient is obviously distended…keep
head of bed up until stomach can be drained.
95
Aspiration of gastric contents
TIPS:
 Cricoid pressure has both bad press and
good but better to do it.
 Any aspiration prevention techniques must be
documented.
 The risk of aspiration may never be
completely eliminated.
96
Respiratory - extubation
TIPS:
 Make sure patient is not in Stage II depth of
anesthesia, respiratory rhythm is regular,
tidal volume adequate, able to lift head and/or
following commands; 4/4 twitches on
Train of Four monitor are present.
 Preformulated reintubation plan
97
Cardiovascular events
 Cardiovascular events occurs most
often during.…


maintenance of general anesthesia
> 50% due to blood loss or
electrolyte mismanagement.
98
Cardiovascular
TIPS:
 All patients get pre-induction EKG –
print out a strip, note ST values
 Patient’s history worrisome?
 Perioperatively, monitor ST segment
changes, electrolytes, labs, ABGs…
 Keep up with blood losses
 Treat electrolyte imbalances
99
Peripheral nerve damage
 Ulnar (25%)
 Brachial plexus (19%)
 Lumbosacral nerve root (92%)
 Spinal cord (13%)
 Successful nerve damage lawsuits due to:



undocumented padding (57%)
undocumented positioning (55%)
improper positioning (36%)
100
Peripheral nerve damage
A 38-year-old female suffered a foot drop after
undergoing a laparotomy. The plaintiff contended
that the defendant was negligent for failing to
properly pad the stirrups.
 The defendant contended that alternate padding
could have posed a larger risk.
Verdict: $400,000
GLASCOCK v. SIMPSON, M.D.
101
TIPS: Peripheral nerve damage
 Meticulous positioning and padding in all
patients.
 Supine position - document “bilateral
shoulders < 90º; bilateral arms on padded
arm boards; cervical spine in neutral position,
etc.”
 Prone position - swimmers position with arms
above head: “bilateral shoulders and elbows
< 90º. Eyes and nose checked q15.”
102
TIPS: Peripheral nerve damage
 Assess and document –
 preexisting
patient conditions and deficits
 positioning
 padding
103
Peripheral nerve blocks
A 72 year old man underwent a nerve block to
his left leg. The patient claimed he suffered
permanent nerve and musculature injury in his
left leg.
Patient
was taking Coumadin
prosthetic
Both anesthesiologists
deniedfor
theaplaintiff's
heart
valve,claims;
The anesthesiologists
not
negligence
they stated theydid
acted
determine
the patient’s
coagulation
profile
within the applicable
standard
of care
at all
before
times. attempting the block. The patient needed
surgery for a hematoma.
Verdict: $127,500
Robert Cormier v. Duane Dixon, M.D.; and Robert Steinberg, M.D.
104
TIPS: Peripheral nerve injury
 Risks are associated with any nerve block.
Nerve damage can occur no matter how
perfect the block is placed or how well
you position the patient….
…protecting yourself comes down to
patient education and documentation!
105
Peripheral nerve blocks
 There is an increase in claims in patients that
receive blocks, especially in anticoagulated
patients.
TIPS
 Assess and document preexisting nerve
deficits and coagulation status before
inserting peripheral nerve block.
106
Drug errors
 Drug-related errors occur in 1 out of 5 doses
hospital patients.
 Annual cost of drug-related errors was
estimated to be $2.8 million for a 700-bed
teaching hospital.
 There are often immediate and major
physiologic effects associated with a drug
administration errors.
 There are many deaths.
107
Drug errors
 While a wide variety of drugs were involved in
drug errors, two drugs in particular were most
commonly involved. In one study  succinylcholine was involved in 35
cases, and
 epinephrine was involved in 17 cases
and had deadliest outcomes
108
Drug errors - Drug
substitution
During an elective hysterectomy on a 64 yo female,
the CRNA believed the patient was low in blood
volume and decided to hang a bag of Hespan.
 Instead of Hespan, a lidocaine drip was hung.
The patient went into cardiac arrest and later
died.
Verdict for $1,560,700
E.D., IND. & AS EXECUTOR OF ESTATE OF F.D., DECEASED v. UNITED STATES OF AMERICA
109
Drug errors
TIPS:
 Bar coding of anesthesia-related drugs in the
operating room has been designed for anesthesia.
 Whether these systems are effective in preventing
drug administration errors is unknown at the current
time.
110
Wrong drug or wrong dose
TIPS:
 Don’t assume!!!
 Check each vial label as you remove from
drawer.
 Label syringe with appropriate label.
 Be able to see the label as you draw up drug into
syringe.
 Check syringe and label before giving drug to
patient.
111
Drug errors - Drug omission
A 53 yo female developed rapid breathing and
tachycardia in PACU after surgery for a fractured
elbow. No temperature was taken for two hours
after surgery. When checked it was 103 degrees F.
Dantrolene was discussed by anesthesiologists but
never given.
 The defendants argued the decedent did not
have malignant hyperthermia and it was not the
cause for her death.
Verdict: $367,360
Leal vs. (1) Freeman, M.D. (2) Latif, M.D. (3) Macklin, M.D.
112
Drug omission in MH case
TIPS:
 When a MH crisis arises, providers must focus
on identification of the problem and rapid
intervention.
 You must be aware the MH can occur during
and 24 hours after at the end of anesthesia.
 Delays in diagnosis of MH greatly increases the
chance of death.
113
Acute Pain Care - postoperatively
 Interaction of sedatives, opioids, and
intermittent monitoring of patient
postoperatively greatly increases risk of
adverse outcomes.
1/3 involved respiratory depression
1/3 involved death or brain damage
114
Postoperative pain care
A patient alleged that she suffered hypoxic
brain damage, with cognitive deficits, when
morphine was administered to her following
knee surgery.
 Claimed that staff negligently administered an
excessive amount of morphine and caused a
lack of oxygen and brain damage.
Verdict: $999,999
PETERSON v. LARAMIE COUNTY MEMORIAL HOSPITAL D/B/A UNITED MEDICAL CENTER
115
Postoperative pain care
A 54-year-old patient recovering from
reconstructive breast surgery suffered
hypoxemia and permanent brain damage after
overdosing on morphine through a patientcontrolled analgesia pump.
 The patient was not on telemetry and was not
considered to be at high risk for respiratory
depression.
Verdict: $1.7 million
Atkisson v. Miami Veterans Affairs Medical Center,
116
NonOperative Pain Management
(NOPM) – peripheral blocks, neuraxial
 Major negative outcomes in chronic pain
management include nerve injury, paralysis, brain
damage, death, meningitis, pneumothorax from –
 Inadequate
 Insufficient
follow-up
monitoring (i.e. continuous pulse
oximeter)
117
Acute & Chronic pain care
TIPS:
 Continuous oxygen monitoring for patient’s




receiving PCA or epidural anesthesia.
Intermittent but frequent neurologic monitoring.
Have narcan readily available.
Patients with OSA may require a higher level of
monitoring…possibly treated with CPAP?
Have both capnography and pulse ox monitors
on high risk patients at all times! (all patients??)
118
Neuraxial Anesthesia
 Sympathetic blockade and cardiovascular
events

54% of cardiac arrests after neuraxial
anesthesia were thought to be
undetected respiratory insufficiency and
sympathetic blockade (profound hypotension).
119
Neuraxial – cauda equina
Plaintiff presented for cesarean, received a
spinal, and allegedly developed severe
hypotension resulting in a permanent and
disabling injury to the cauda equina.
 Defendants' claimed that plaintiff's injuries
were more consistent with childbirth than with
medical malpractice.
 Last Demand: $2,500,000
 Last Offer: None
C.K. v. COUNTY GENERAL HOSPITAL, MB, M.D., SJ, M.D. AND IH, M.D.
120
Neuraxial – neuro deficits
A woman received epidural analgesia
postoperatively after total knee replacement.
 She contended that she continued to receive
epidural medication for two and one-half days
even though she suffered increasing
neurological deficits in her legs and feet.
Verdict: $5 million
Bothe, et al. v. DelaCruz et al., Lee County Illinois 1999
121
Neuraxial - paraplegia
A 62-year-old female alleged that she suffered a
spinal nerve injury that resulted in total paraplegia
after she received a spinal catheter after a vehicle
accident.
Verdict: $22 million
DVG, M.D.; K, M.D.; R, M.D.; W, M.D.; Southern XXXX Medical Center
122
Spinal vs. epidural - death
A 20-year-old woman in labor received epidural
analgesia. She was found 20 minutes after an infusion
pump for the epidural had been started. She was in
cardiopulmonary arrest.
 Plaintiff contended that the anesthesiologist and
CRNA failure to recognize that the medication was
being given into the subarachnoid space rather than
the epidural space and failed to properly monitor the
mother’s vital signs.
Verdict $2.3 million
123
Britteny And Ariel Lingold, Minors, B/N/F And Natural Father, William Lingold, Jr. V. John Bowden, M.D. And Rockdale Anesthesia
Spinal vs. epidural - death
25 year old female was in labor with her second child.
Defendant anesthesiologist administered an epidural at
the patient’s request. For ~ 30 mins, the patient was
awake and alert.
 The patient then went into cardiopulmonary arrest.
 Plaintiff alleged that defendant negligently
administered the epidural in the spinal space instead
of the epidural space.
 Last Demand: $2,000,000
 Last Offer: $100,000
124
Neuraxial anesthesia
TIPS:
 Patient is nauseous? – immediately check
blood pressure, treat if hypotensive.
 Sympathetic blockade and cardiovascular
event practice suggestions –
 Prophylactic atropine administration
 Use of epinephrine early in resuscitation
125
Neuraxial anesthesia
TIPS:
 Severe hypotension can occur even with appropriate
local anesthetic doses
 Constant vigilance and preparedness for emergency
management of airway, breathing, and circulation is
paramount
 This vigilance requires frequent monitoring of the
anesthetic dermatome level as well as the patient’s vital
signs and ability to communicate verbally
126
Neuraxial anesthesia
TIPS:
 Again, occurrence of side effects does not in itself
indicate negligence; negligence is likely to occur when
providers fail to monitor and react appropriately if such
effects occur.
127
Burns
 Burns attributable to –
IV bags or bottles (35%)
 Warmers (23%)
 Cautery with fire (19%)
 Cautery without fire (12%)
 Airway lasers (2%)
 MRI at pulse oximetry site (2%)
 Defibrillator paddles ((1%)
 EKG leads (1%)

128
Airway Fire
The plaintiff alleged that
the fire started when a
Bovie ignited 100%
oxygen that was being
administered by a CRNA.
 The fire resulted in
burns to patient’s throat
and face.
Verdict: $250,000
129
Burns
TIPS:
Prevent burns by:
Arrange surgical drapes to avoid trapping high
concentrations of oxygen; avoid nitrous oxide.
Communication with surgeon is KEY when
using laser or cautery during surgery
FiO2 decreased as low as possible when
either laser or cautery is used
 Do not use Bair Hugger tube
without connecting to upper or
lower body Bair blanket
130
Eye injuryPostoperative Visual Loss (POVL)
 81% of POVL claims related to ischemic
optic neuropathy and correlated with large
blood losses, prolonged hypotension, prone
positioning, and vaso-occlusive disease.
 13% of POVL claims correlated with direct
pressure on the eye globe, emboli and low
retinal perfusion pressure.
131
Eye injury
TIPS:
 Maintain mean arterial pressures at > 60-70 mm Hg




especially for patient in prone or sitting positions.
Maintain hemoglobin > 9.4
Keep neck in midline to prevent venous congestion in
the head.
Normothermia, euglycemia, and urinary output
> 0.5 mL/kg/hr.
Chart “eyes and nose check” along with vital signs on
anesthesia record in any patient in prone position.
132
Central Venous Line
 Increase in CVP-related claims in last decade
from both injury and death due to
 cardiac tamponade
 vascular injury.
TIPS:
 Almost half of these claims deemed
preventable by the implementation of ultrasound,
 waveform to confirm cannulation of vein,
 interval or continuous waveform monitoring.

133
Peripheral IV
 Liability from peripheral catheters: 2% of
database
 Median payout $50,000
 Most claims due to soft tissue injury from IV
catheter (extravasation);
strongest association occurred in setting of
cardiac surgery;
 results from delayed recognition of IV catheter
malfunction in tucked arm.

134
Peripheral IV
TIPS:
 Especially with caustic or vasoactive additives
in solution…can cause tissue destruction.
Certain drugs should only be given by central
line.
 Questionable PIV?…taped securely, ability to
check during surgery…don’t just force fluid
through.
 Have multiple PIV when arms are tucked and
can’t get to them during surgery.
135
Awareness/Recall
 Substandard care judged in 42% of cases
involving intraoperative awareness and due
to:
 Failure to turn on agent vaporizer
 Vaporizer malfunction
 Failure to anesthetize sufficiently during
induction
 Inadvertent paralysis of conscious patient
136
Awareness/Recall
 Recall claims occurred most often during
general anesthesia given to Women
 Opioids used
 Muscle relaxation used
 No volatile anesthetic used

137
Awareness/Recall
TIPS:
 Prevent awareness –
Use BIS monitor, maintain between 40-60
Monitor for unexpected tachycardia and or
hypertension
Monitor volatile anesthetic levels in vaporizers
“The most important “monitor”
is the anesthesia provider.”
138
Fast-tracking
TIPS:
 The medications and techniques used in
fast-tracking must be part of a carefully
planned program with close surveillance of
patients and outcomes.
139
Important to remember…
 Mistakes by humans are inevitable BUT they
become either difficult to correct or
permanent when not caught early.
 We must be prepared for something to go
wrong – inspect your work at every step and
frequently during care!
140
Worst Outcomes in CRNA database
Not Correlated
Correlated with outcomes
 Preop physical status
 Patient age

Inappropriate care
 Lack of vigilance
 Preventable outcomes
 Airway incidents
 Type of surgery
 Age of anesthesia
provider
 Years of CRNA
certification
141
In defense of your care…
While unforeseen difficulties can occur,
even with poor outcomes,
the defense of the anesthesia provider
may focus on
the lack of forseeability and that
appropriate crisis interventions were provided.
142
How to help avoid patient injury and
being named in a lawsuit
We must improve identification of high-risk
patients and recognize the insufficiency of
intermittent monitoring, and move toward
having continuous monitors on
high-risk patient at all times.
143
How to help avoid patient injury and
being named in a lawsuit
Aware and mindful check of anesthesia
machine and all equipment before every case
Have plenty of choices and sizes of
endotracheal tubes, LMAs, laryngoscope
blades, suction, emergency airway equipment
(bougie’s, Glidescope, etc.)
144
How to help avoid patient injury
and being named in a lawsuit
Be Prepared for Emergencies
Basic emergency care and back-up plans are
an integral part of anesthetic care.
145
How to help avoid patient injury and
being named in a lawsuit
Perform a thorough assessment of patient’s
airway and Mallampati score. Ask if patient
has had previous anesthetic and/or ever been
told they have a “difficult airway”?
Anticipate or known difficult airway?
Where is difficult airway cart?….need an airway
surgeon?....have Glidescope in room?....have
extra anesthesia providers in the OR?
146
How to help avoid patient injury and
being named in a lawsuit
Address specific risks based on patient’s
medical/surgical history.
Obtain informed consent for the
patient-specific planned anesthetic.
Discuss common anesthetic risks and
chart conversation.
147
How to help avoid patient injury and
being named in a lawsuit
Check your syringe and drug vial before, during,
and after drawing up a drug.
Check labels before starting drug or drip.
Consider patient’s history and allergies before
starting drug or drip.
148
How to help avoid patient injury and
being named in a lawsuit
Monitor the patient’s physiologic condition as
appropriate for the anesthetic.
Implement and adjust the anesthetic based on
the patient’s physiologic response.
Monitoring includes patient position.
149
How to help avoid patient injury
and being named in a lawsuit
Don’t just extubate a patient at the end of the
case!
Any question of fluid overload, assess the
patients ability to breathe around the ETT.
150
How to help avoid patient injury and
being named in a lawsuit
Of all pertinent information - show physiologic
responses, adjustments that are made, and
outcome from those interventions.
Chart “who” knew “what”,
and “when” they knew it.
151
If you do it?
152
A huge truth!
Good documentation supports
your defense…
while poor documentation
supports the plaintiff’s case.
153
Thank you very much!
What
questions
do you have?
154
The End
155