Changes in clinical practice in response to reductions in reimbursement: physician autonomy and resistance to bureaucratization.

This analysis of field data from 1991 and 1992 examines the process of joint decision making between cardiothoracic surgeons and anesthesiologists in a U.S. hospital as they made changes in clinical practice in response to reimbursement reductions. Although these physicians have concurrent responsibility for patient care in the operating room, their domains of authority are ambiguous. Much clinical decision making was found to be based on charismatic authority. In making practice changes, cardiothoracic surgeons maintained all and anesthesiologists most of their charismatic authority, expanding the conventional range of physician practice while prescribing specific practices for nonphysician providers. Ambiguity of joint physician authority over patient care was left unresolved, and the economic goals of the practice changes were not realized. Physicians resisted the bureaucratic claim to authority rooted in cost accounting by resorting to the need for nonroutinized clinical decisions.

Burns from warming devices in anesthesia. A closed claims analysis.

BACKGROUND: Prevention of hypothermia is an important aspect of anesthetic management. Methods used for its prevention may, however, cause cutaneous burns. We reviewed the American Society of Anesthesiologists (ASA) Closed Claims Project database to determine if there were recurrent patterns of injury arising from intraoperative warming methods. METHODS: The ASA Closed Claims Project database is a collection of closed malpractice claims that have been reviewed in a standardized format. All claims for burns were reviewed. RESULTS: Among the 3,000 total claims there were 54 burns, of which 28 resulted from materials or devices used to warm patients. Intravenous fluid bags or bottles warmed in an oven and then applied to the patient's skin were responsible for 18 of the 28 (64%) burns associated with warming devices. These burns from intravenous fluid bags or bottles occurred in predominantly healthy (ASA physical status 1-2) young (age 38 +/- 17 yr, mean +/- standard deviation) women undergoing routine gynecologic or peripheral orthopedic surgery under general anesthesia. Of the eight burns from electrically powered warming equipment, five resulted from circulating-water mattresses. CONCLUSIONS: Intravenous fluid bags or bottles warmed in an operating room oven represent a hazard to anesthetized patients. Because intravenous fluid bags or bottles are not an efficient method of patient warming, there seems to be little justification for their use.

Risk management in cardiac anesthesia: the ASA Closed Claims Project perspective.

The ASA Closed Claims Project has generated a standardized collection of case summaries of adverse anesthetic outcomes, with the objectives of identifying major areas of anesthesiologist liability and the contribution of substandard care to anesthetic injury. Seventy-six (3%) of the files in the project's current database of over 2,400 case summaries are for anesthesia-related injuries sustained during cardiac surgery. The most common adverse outcomes in the cardiac surgical group were death (36%), brain damage (16%), stroke (13%), and nerve damage (11%). Equipment malfunction or misuse was responsible for 37% of the adverse outcomes in the cardiac group, compared with only 9% in the noncardiac group (P = < 0.01). Conversely, respiratory-related damaging events were responsible for only 9% of adverse outcomes in the cardiac group, compared with 32% of adverse outcomes in the noncardiac claims (P = < 0.01); incidences of damaging events related to the cardiovascular system and those events related to inadequate or inappropriate fluid therapy were similar in both groups. Although there are several important limitations intrinsic to closed-claims analysis, data from the Closed Claims Project suggest that careful attention to IV catheter management and cardiopulmonary bypass equipment will reduce the risk of injury to patients.

Linking process and outcome of care in a continuous quality improvement program for anesthesia services.

We developed a continuous quality improvement (CQI) program for anesthesia services based on self-reporting of critical incidents and negative outcomes through a dichotomous (yes/no) response on the anesthesia record. Immediate case investigation provides data for systematic peer review of anesthesia management. Trend analysis of the database of critical incidents and negative outcomes identifies opportunities for improvement. The CQI program resulted in the reporting of nearly twice as many problems related to anesthesia management (5% of all anesthetics) as did the checklist it replaced (2.7%). Escalation of patient care (3.2%) and operational inefficiencies (2.2%) were more common than patient injury (1.5% of all anesthetics). Among the 537 cases with anesthesia management problems were 119 human errors and equipment problems (22%). Regional nerve blocks and airway management represented the most common problem areas. Improvement in anesthesia services was made through prompt implementation of strategies for problem prevention devised by the practitioners themselves through peer review, literature review, and clinical investigations.

A comparison of pediatric and adult anesthesia closed malpractice claims.

BACKGROUND: Since 1985, the Committee on Professional Liability of the American Society of Anesthesiologists has evaluated closed anesthesia malpractice claims. This study compared pediatric and adult closed claims with respect to the mechanisms of injury, outcome, the costs, and the role of care judged to be substandard. METHODS: Using a standardized form and method developed for analysis of closed claims, the American Society of Anesthesiologists Closed Claims Data Base was used to compare pediatric with adult anesthesia-related adverse events. RESULTS: Of the 2,400 total claims, 238 (10%) were in the pediatric age group (15 yr of age or younger). The pediatric claims presented a different distribution of damaging events compared with that of adults. In particular, respiratory events were more common among pediatric claims (43% versus 30% in adult claims; P < or = 0.01). The mortality rate was greater in the pediatric claims (50% versus 35% in adult claims; P < or = 0.01), anesthetic care more often was judged less than appropriate (54% versus 44% in adult claims; P < or = 0.01), the complications more frequently were thought to be preventable with better monitoring (45% versus 30% in adult claims; P < or = 0.01), and the distribution of payments to the plaintiff was different (median payment, $111,234 versus $90,000 in adult claims; P < or = 0.05). Many of the differences between pediatric and adult claims were explained by a higher prevalence of patient injury caused by inadequate ventilation in the pediatric claims (20% versus 9% in adult claims; P < or = 0.01). In pediatric compared with adult inadequate ventilation claims, poor medical condition and/or obesity (6% versus 41%; P < or = 0.01) were uncommon associated factors. Cyanosis (49%) and/or bradycardia (64%) often preceded cardiac arrest in pediatric claims related to inadequate ventilation, resulting in death (70%) or brain damage (30%) in previously healthy children. Although clinical clues suggested hypoxemia as a common mechanism of injury, the files did not contain enough information to explain the genesis of hypoxemia in these claims. CONCLUSIONS: Comparison of adult and pediatric closed claims revealed a large prevalence of respiratory related damaging events--most frequently related to inadequate ventilation. In the opinion of the reviewers, 89% of the pediatric claims related to inadequate ventilation could have been prevented with pulse oximetry and/or end tidal CO2 measurement. However, pulse oximetry appeared to prevent poor outcome in only one of seven claims in which pulse oximetry was used and could possibly have done so.

Eye injuries associated with anesthesia. A closed claims analysis.

Claims against anesthesiologists for eye injuries were analyzed as part of the ASA Closed Claims Project. Eye injury occurred in 3% of all claims in the database (71 of 2,046). The payment frequency for eye injury claims was higher than that for non-eye injury claims (70% vs. 56%; P less than or equal to 0.05). The median cost of eye injury claims was less than that for other claims ($24,000 vs. $95,000; P less than or equal to 0.01). Two distinct subsets were identified. The first was characterized by corneal abrasion during general anesthesia (25 of 71 claims; 35%). Claims for corneal abrasion were characterized by low incidence of permanent injury (16%) and low median payment ($3,000). Reviewers were able to identify a mechanism of injury in only 20% of claims for corneal abrasion. The second subset of eye injury was characterized by patient movement during ophthalmologic surgery (21 of 71; 30%). Blindness was the outcome in all cases. Sixteen of the claims involving movement occurred during general anesthesia, and 5 occurred during monitored anesthesia care. The median payment for claim involving movement was 10 times greater than for non-movement claims ($90,000 vs. $9,000; P less than or equal to 0.01). Anesthesiologist reviewers deemed the care rendered in the general anesthesia "movement" claims as meeting standards in only 19% of claims. From the perspective of patient safety, as well as risk management, these data suggest two specific needs: research directed at better understanding of the etiology of corneal abrasion and clinical strategies designed to assure patient immobility during ophthalmic surgery.

Informed consent: a review.

Of paramount importance is the respect for autonomy and right to self-determination inherent in an ethically sound decision-making process. The President's Commission clearly summarized the prevailing view of informed consent when it stated: "ethically valid consent is a process of shared decision making based on mutual respect and participation, not a ritual to be equated with reciting the content of a form that details the risks of a particular treatment or intervention".