In June 2019, we repeated the study for 587 claims that closed between 2013–2018. The goals for these parallel studies were to determine whether the number of patient injuries had decreased and to identify any new trends in claims involving anesthesia care.
We segregated claims alleging tooth damage (272 claims) and reviewed them separately. Rates of claims and costs of claims (indemnity and expense) were compared between time periods for all anesthesiology claims. Pain medicine claims were also excluded from these studies.
|Study years||All claims||Claims for tooth damage||Claims excluding tooth damage|
Anesthesiology Claim Frequency and Cost
Anesthesiology has led other specialties in reducing the risk of harm to patients since the mid-1980s, when the Anesthesia Patient Safety Foundation (APSF) was founded. Since then, clinical practice guidelines have been published by APSF and the American Society of Anesthesiologists (ASA), which have standardized some aspects of anesthesia practice.
Expectations are high to make administration, management, and monitoring of anesthesia safer because of the significant improvements to care with pulse oximetry, capnography, ultrasound-guided central line placement, transesophageal echocardiogram (TEE) monitoring, screening for obstructive sleep apnea, airway classifications, and patient health classifications.
The frequency of claims, including lawsuits, filed against anesthesiologists stayed the same for nine years (2005–2013). A small decrease in the rate of claims, between 1 and 2 percent, occurred in 2014 and in 2015. The decrease in the rate for the 14 years was less than 3 percent.
When compared to the reduction in the number of claims filed per 100 FTEs in other specialties, the percent reduction for anesthesiologists was very small. Even if we associate fewer claims with fewer patient injuries, the best that can be said is that there has been only slight improvement.
Clinical services with 40 or more paid claims sorted by mean indemnity 2013–2018:
Anesthesiology median indemnity was 19th out of 25 clinical services between 2013 and 2018.
Clinical services with 40 or more paid claims sorted by median indemnity 2013–2018:
Anesthesiology Tooth Damage Claims
Tooth damage claims continue to make up almost a quarter of all anesthesiology claims (22 to 23 percent). Although tooth damage claims are less expensive than most other types of anesthesia-related injuries, their processing and handling costs can impact the cost of medical malpractice insurance.
Tooth damage claims as a percentage of all anesthesiology claims:
of all anesthesia claims
of all anesthesia claims
Rate of paid tooth damage claims:
of tooth damage claims
of tooth damage claims
Mean indemnity for paid tooth damage claims:
Median indemnity for paid tooth damage claims:
Mean expense for paid tooth damage claims:
Median expense for paid tooth damage claims:
Tooth damage claims are ubiquitous in situations where intubation is necessary. The numbers captured in our system are not fully representative of all tooth damage claims experienced by the physicians and organizations insured by The Doctors Company. Some groups and organizations choose to adjudicate these claims without submitting them to their professional liability insurance company.
Some patients have anatomy that creates challenges to intubation and other patients have poor dentition. It is essential to evaluate patients preoperatively to determine their dental condition and airway challenges. Plan for airway techniques least likely to damage teeth at risk. In cases of short neck, overbite, limited neck extension, and other anatomical challenges, anesthesia professionals can take precautions against tooth damage. In case of poor dentition and severe gum recession, patients need to be aware of risks to their teeth.
Factors that Contributed to Tooth Damage
In most tooth damage cases, documentation indicated that patients were informed of the risk of tooth damage. The injury was known to the patient as a risk of the procedure (84 percent). In only 3 percent of tooth damage cases was poor technique identified.
The other primary factor determining the outcome of these cases was documentation (13 percent). The two areas of inadequate documentation were lack of descriptive preoperative clinical findings related to dentition, airway, and anatomy and informed consent listing tooth damage as a risk.
According to claims specialists, defense of tooth damage claims is more likely to be successful when anesthesia professionals document the preoperative condition of patients’ dentition, record descriptions of airways, and choose an appropriate intubation process.Anesthesiology Claims Excluding Cases with Tooth Damage
More than one in five anesthesia claims (22 to 23 percent) allege tooth damage. For this reason, we segregated tooth damage claims from all other anesthesia claim types to provide clear insights to the other anesthesia patient management issues.
|Anesthesiology tooth damage claims||Claims and suits excluding teeth damage claims||Paid claims||Percent of claims with payments|
In cases excluding tooth damage, mean indemnity and expense increased by 12.5 percent and 36.0 percent respectively between the two time periods included in this study.
Anesthesiology claims mean indemnity for paid claims:
An increase of $46,657 (12.5 percent)
Anesthesiology claims mean expense for paid claims:
An increase of $38,111 (36.0 percent)
Median indemnity did not increase when the two time periods were compared. However, median costs for defense (expense) of anesthesiology claims increased by 37.1 percent.
Anesthesiology claims median indemnity for paid claims:
An increase of $0.00 (0 percent)
Anesthesiology claims median expense for paid claims:
An increase of $26,157 (37.1 percent)
When tracked by year, trend lines for mean and median indemnity and expense have increased over time.
Mean Indemnity and Expense for Anesthesiology Claims by Year
Median Indemnity and Expense for Anesthesiology Paid Claims by Year
The trend for more expensive anesthesia claims and suits continues. In 2009, only 19 percent of claims resulted in payment greater than $500,000, but by 2018, this category rose to 36 percent of anesthesiology claims. Most anesthesiology claims remain in the $1 to $499,000 range but the percentage of claims in this category decreased over the last 12 years, from 81 percent in 2009 to 64 percent in 2018.
Anesthesia Claims by Value Range
Anesthesiology Injuries Excluding Tooth Damage
The second study found the same types of injuries and at the same percentage of claims as in the first study. Along with a slight decrease in the frequency of anesthesiology claims, it appears that even with the introduction of new technology in recent years, the safety of anesthesia care has not changed in more than a decade. Maybe technology is not the only area where improvements can be made.
Note that the number differences may not be statistically significant. Also, patients may suffer more than one injury so the total is greater than 100 percent.
Top 10 Anesthesia Patient Injuries
|Injury||Claim count 2007–2012||Percent of total 2007–2012||Claim count 2013–2018||Percent of total 2013–2018|
|Cardiac or respiratory arrest||68||14%||87||19%|
|Need for surgery||36||7%||45||10%|
|Puncture or perforation||33||7%||39||8%|
*In 2007 through 2012, 98 percent of organ damage claims were brain injuries. In 2013 through 2018, 93 percent of organ damage claims were brain damage injuries.Comorbidities in Anesthesiology Claims Excluding Cases of Tooth Damage
Across anesthesia claims (excluding tooth damage claims) there was not much change in the percentage of claims where these comorbidities impacted the patients’ clinical results. The greatest increase was seen in hypertension, from 3 percent in the earlier study to 9 percent in the 2013–2018 study.
However, there was a sizable impact of comorbidities—patients who suffered harm as a result of improper anesthesia management during surgery—when compared to all other anesthesia claims.
|No comorbidity impact on outcome of care||71%||59%|
|Obstructive sleep apnea||2%||5%|
*Note that coding of comorbidities in medical malpractice claims began in 2010 (partial year) so studies of comorbidities began in 2011.
Most Frequent Anesthesiology Case Types Excluding Tooth Damage
The three most common case types made up 63 percent of anesthesia claims in 2007–2012 and 65 percent in 2013–2018.
|Anesthesia case types excluding tooth damage||Claim count 2007–2012||Percent of claims 2007–2012||Claim count 2013–2018||Percent of claims 2013–2018|
|Improper performance of anesthesia procedure||169||34%||126||27%|
|Improper management of patient under anesthesia||110||22%||145||32%|
|Improper management of surgical patient||31||6%||25||5%|
|Improper performance of treatment or procedure||25||5%||15||3%|
In the first study (2007–2012), improper performance of anesthesia procedure (intubation, injection of anesthesia into a peripheral nerve, injection of anesthesia into spinal canal) was the most common type of claim or suit. It decreased in injuries in the later years. It was proposed at the time that the decline may be due to the introduction of new technologies, like ultrasound-guided regional anesthesia. The downward trend continued in the 2013–2018 study, dropping to 27 percent of anesthesia claims. However, the second study (2013–2018) found that the case type of improper management of patient under anesthesia increased by 10 percent from the earlier study.
Top Two Case Types as a Percentage of Anesthesiology Claims by Year
Twenty-four other case types made up the remaining 37 percent and 35 percent of anesthesiology claims in these two time periods.
Case Type: Improper Management of Patient Under Anesthesia
Claims identified as improper management of patient under anesthesia were due primarily to respiratory, central nervous system, and cardiac complications. These complications were due to comorbidities that were present before the patient was taken to surgery.
Claims of this case type, with inadequate history and physical as a contributing factor, averaged more than two comorbidities per patient. In these cases, 67 percent of the patients had at least one comorbidity. This was two times higher than the percentage of claims with a comorbidity for the rest of the anesthesia cases where only about a third of cases had a comorbidity that impacted the outcome of care.
|Comorbidities for anesthesia claims (excluding tooth damage) including all case types except improper management of patient under anesthesia, 2013–2018||Percent|
|Obstructive sleep apnea||4%|
|Chronic pulmonary disease||2%|
|No comorbidities impacted the outcome of care||64%|
|Comorbidities for anesthesia claims with the case type improper management of patient under anesthesia (including contributing factor, inadequate history and physical) 2013–2018||Percent|
|Obstructive sleep apnea||25%|
|Chronic pulmonary disease||17%|
|No comorbidities impacted the outcome of care||33%|
In claims of improper management of patient under anesthesia with inadequate history and physical as a contributing factor, obesity impacted patients’ care in almost three times as many cases as other anesthesia cases. Obstructive sleep apnea was six times more likely to impact the outcome. Hypertension was three times more likely to impact patient’s surgical results. The other comorbidities impacted care outcomes more than twice as frequently.
In these cases, anesthesia providers were managing conditions unrelated to the purpose of surgery but that ultimately were the cause of the patient harm. It appears that many patients were not healthy before surgery started.
Less common comorbidities and other conditions that complicated surgery included clotting disorders (factor 5 mutation), low potassium, interrupted aortic arch, CVA, anticoagulants, asthma, advanced patient age, CHF or COPD, previous damage to airway, MVA and other trauma, pregnancy, and alcoholism.
A review of these cases revealed limited opportunities to conduct preoperative assessments. Older and sicker patients needed closer investigation but production pressures often limited testing and input from attending or referral physicians. These pressures also limited anesthesia professionals’ opportunities to recommend safer locations for anesthesia care (e.g., hospital operating room vs. ambulatory surgery or GI or cardiac labs) or to prepare for complications that might occur as a result of multiple comorbidities or complicated health histories.
Increases in complications and injuries for patients in cases with improper management of patient under anesthesia was also seen in the severity of patient injuries. These patients suffered high-severity injuries in 62 percent of these cases compared with 16 percent of high-severity injuries in all other anesthesiology cases (excluding tooth damage cases).
This highlights the potential for harm in patients with comorbidities and who may not have had adequate history and physical examinations prior to surgery. This data raised the following questions:
- Were the comorbidities known prior to administration of anesthesia?
- Did anesthesiologists and CRNAs have opportunities to adequately assess patients in advance of surgery? Pre-op assessments are important for the anesthesia professional to determine ASA and Mallampati scores and to prepare to handle complications that may result from comorbidities (bleeding, respiratory complications, mean arterial pressures, cardiac conditions).
- Did anesthesia professionals have opportunities to refer patients to specialists to evaluate patients’ comorbidities?
- Did anesthesia professionals take adequate precautions and make adequate preparations before anesthetizing patients with comorbidities?
- Should additional steps be taken prior to surgery for patients who have comorbidities?
Patients may suffer from a wide variety of comorbidities. Some may not be discovered without a thorough history and physical including family history of cardiovascular disease, respiratory conditions, allergies or bleeding disorders.
Other conditions that impacted the outcome of anesthesia care included aspiration of stomach contents; sudden drop in oxygen saturation, blood pressure, and/or heart rate; laryngospasm; and low mean arterial pressures. Anatomical structures like tracheal stenosis and short neck, caused difficult intubations and prone positions caused displacement of endotracheal tubes.
Factors that contributed to patient injuries in the case type improper management of patient under anesthesia included improper selection and management of therapy (44 percent). In most cases, this referred to management of complications that occurred during surgery. Fifty-five percent of these cases had respiratory complications, central nervous system complications, adverse effects of anesthesia, or cardiac complications.
This also referred to the types of anesthesia and the routes of anesthesia that were selected for these patients. Reviewers pointed to patients’ conditions or comorbidities that should have prompted anesthesia professionals to consider other options.
Almost all factors related to patient monitoring were for inadequate monitoring of patients’ physiological status. Low mean arterial pressure and severe acidosis resulted in blindness. A drop in end-tidal CO2, likely due to an airway obstruction, was not noted and resulted in encephalopathy and death. Lack of documentation of breath sounds and slow response to drop in CO2 and heart arrhythmia resulted in anoxic brain injury. A patient’s oxygen levels dropped rapidly, and the low pulse oximeter readings were assumed to be due to equipment malfunction. It was later discovered that breathing circuit tubes had disconnected.
Case Type: Improper Performance of Anesthesia Procedure
In the most recent study, improper performance of anesthesia procedure was the second most common case type, accounting for 27 percent of anesthesia claims. The factor identified most frequently by physician experts as having contributed to patient injury was technical problems that were known risks of the procedure (88 percent of the cases of this type). In these cases, patients were aware of the risks prior to surgery. Only 11 percent of these cases were due to poor technique.
This factor was identified in procedures such as intubation of the respiratory tract (46 percent), injection of anesthesia into peripheral nerve (27 percent), injection of anesthesia into spinal canal (14 percent), and injection of anesthesia into a sympathetic nerve (2 percent). Intubation cases resulted from injuries during intubation or from improperly located endotracheal tubes, causing hypoxia. Injection of anesthesia into spinal canal cases occurred when the injection was incorrectly placed as spinal and not epidural anesthesia.
Injection of anesthesia into a peripheral nerve or peripheral nerve blocks sometimes resulted in nerve damage from inadvertent injection into nerves. The frequency of these cases has decreased in recent years due to the use of ultrasound-guided needle placement. In a few of these cases, it was speculated that the injury came from the tourniquet. As with all cases, lack of or inadequate documentation (18 percent) may have impacted the quality of care and later, the ability of anesthesiologists to defend the care that they provided.
|1. Technical performance||88%|
|A. Injury was known to the patient as a risk of the procedure||77%|
|B. Poor technique||11%|
|2. Insufficient or lack of documentation||18%|
|A. Informed consent||9%|
|B. Review of participation of care||5%|
|C. Clinical findings||3%|
|3. Selection and management of therapy||8%|
|A. Invasive procedures||4%|
|B. Medication related||2%|
|4. Communication among providers||7%|
|A. Regarding patient’s condition||2%|
|B. Information lost in transition of care||2%|
|C. Failure to read medical record||3%|
Observations and Summary
- Claims filed against anesthesiologists have historically occurred less frequently than claims experienced by other specialties. However, other specialties have experienced gradually decreasing rates of claims while anesthesiology has remained between 3 and 6 percent of the cases for the last 14 years. This raises the question, what do anesthesia professionals need to do to continue to reduce the frequency with which claims are filed? A study of these claims and suits seems to indicate that inadequate preoperative assessments were a significant factor.
- The mean indemnity for anesthesiology claims placed this specialty 12th out of 25 clinical services in the years 2013–2018. Anesthesiology median indemnity was 19th out of 25 clinical services during those same years.
- Tooth damage claims continue to make up almost a quarter of all anesthesiology claims (22 percent to 23 percent). Although tooth damage claims are less expensive than most other types of anesthesia-related injuries, their processing and handling costs can impact the cost of medical malpractice insurance, and tooth damage is a source of great patient dissatisfaction.
- According to claims specialists, defense of tooth damage claims is more likely to be successful when anesthesia professionals document the condition of patients’ dentition, document airway anatomy, and record the intubation process.
- The trend for higher indemnity in anesthesia claims and lawsuits, continues. Since 2009 when only 19 percent of indemnity payments were greater than $500,000, the percentage of indemnity payments in 2018 that was greater than $500,000 jumped to 36 percent.
- The cost of defense of anesthesia claims continues to increase. The trend lines over the last 12 years shows upward slopes. Both mean and median defense costs increased by more than 36 percent when comparing costs of claims between 2007–2012 and 2013–2018 study years.
- The most common case type in the 2007–2012 study was improper performance of anesthesia procedure. However, in that study, we saw a downward trend over those years for this case type. That finding was borne out in the 2013–2018 study where we found that the case type improper performance of anesthesia procedure dropped by 7 percent and became the second most common case type.
- In the 2007–2012 study, the case type improper management of patient under anesthesia was the second most common. In the 2013–2018 study it was the most common, having increased by 10 percent between the two studies.
- Claims identified as being improper management of patient under anesthesia, were due primarily to respiratory, central nervous system, and cardiac complications. These complications were due to comorbidities that were present before the patient went to surgery.
- Claims with the allegation improper management of patient under anesthesia averaged more than two comorbidities per patient. In these cases, 67 percent of the patients had at least one comorbidity. This was two times higher than the percentage of claims with a comorbidity for the rest of the anesthesia cases where only about a third of cases had a comorbidity that impacted the outcome of care.
Risk Mitigation Strategies
The following strategies can assist physicians and other providers in reducing risk and improving quality of care:
- Include information in informed consent discussions about anesthesia risks including special positioning risks and risks of special procedures like nerve blocks and arterial lines. Patients with dental appliances or poor dentition should be informed of the risks.
- Work with surgeons, proceduralists, and healthcare organizations to ensure adequate time for preoperative assessments and testing. Some anesthesiologists report pressure to proceed with surgery when they have not had time to do more than a cursory review of the patient and his or her history.
- Include a review of the patient’s previous experience with anesthesia in the history and physical. When possible view previous anesthesia records.
- Tailor anesthesia plans for each patient to specifically address any abnormal findings or comorbidities identified during the history and physical.
- Fully document the preoperative anesthesia assessment. In one case discussed in this study, the existence of obstructive sleep apnea should have dictated removal of endotracheal tube or LMA only after the patient was awake and able to respond. Patients with difficult airways should be awake and able to respond to commands before airways are removed.
- After patients are extubated, airways sometimes close due to obstructive sleep apnea, neck swelling, hematomas, laryngospasms, etc. For these reasons, equipment for performing emergency cricothyrotomies or tracheostomies must be immediately available in case attempts to reintubate fail.
- Patients may suffer from a large variety of comorbidities. Some may not be discovered without a thorough family history of cardiovascular disease, respiratory conditions, allergies, or bleeding disorders. Prompt patients to be prepared to discuss family history before presenting for preoperative assessments.
- Even fasting patients may accumulate large amounts of fluid in their stomachs. Caution should be taken when intubating to reduce the chance of aspirating vomit.
- One complication of placing patients in the prone position is inadvertent dislocation of endotracheal tubes. Close monitoring of these patients is important. The surgeon should be notified if there are concerns about respiration rates, end-tidal CO2 levels, oxygen saturation, or any other monitored metric or vital sign.
- Mean arterial pressure is a factor in cases involving bleeding and in cases involving positioning. Patients can suffer brain injury from inadequate oxygenation during surgery if the mean arterial pressure and cerebral perfusion pressure are not maintained within a safe range for each patient.
- The most common procedures in cases of alleged improper performance of anesthesia procedure include intubation of respiratory tract and injection of anesthesia into peripheral nerve, spinal canal, or sympathetic nerve. The most effective defense is good documentation.
- The most common factor that contributed to patient injury was complications of the procedure. These injuries were known to patients as risks of the procedure. Poor technique was found in only about 11% of anesthesia cases. When patients suffer from known complications, create opportunities to talk with patients and/or their families. Patients may not remember informed consent discussions or the content of the consent form document they were provided, and may not understand that the injury that they experienced was known as a risk of the procedure. Help patients understand and offer to answer their questions, thus building trust and providing explanations that patients deserve.
- Decisions about providing care to patients in the appropriate setting is often made by anesthesiology professionals. Pre-op assessments performed at least a week in advance of surgery provide time to schedule patients at an appropriate location where a higher level of care is available if needed.
- Documentation is essential for providing good care and for defending that care, often years after the services were provided.
Rare situations don’t require extensive discussion since anesthesia professionals know how to provide high-quality care. However, the following circumstances from case reviews may be instructive, so they are included here:
- The patient was given a paralytic agent but not anesthetized (failed to turn on the anesthetic gas so there was a period of awareness).
- Records were suspected of being fabricated because they did not fit the clinical picture.
- Burns from radiation or previous surgeries resulting in scar tissue made intubation difficult—not identified in the patient’s history and physical pre-op assessment.
The purpose of this study is to identify those rare circumstances that result in patient harm. Although anesthesia professionals provide excellent care for almost every patient, there is value in seeing those situations where circumstances prevented good care.Our hope is that this summary of data that arose from medical malpractice claims will serve as a reminder that excellent clinicians can find themselves in situations where they are fighting to save patients’ lives. This data shows that comorbidities can complicate the delivery of good anesthesia care. It reinforces the importance of thorough histories and physicals as a way of identifying potential problems and preparing to address them in the administration of anesthesia care.
Ranum D, Shapiro F, Chang B, Urman D. Analysis of patient injury based on anesthesiology closed claims data from a major malpractice insurer. J Healthc Risk Manag. 2014;34(2):31-42