Delayed Detection of Esophageal Intubation in Anesthesia Malpractice Claims: Brief Report of a Case Series

AUTHORS: Honardar, Marzieh, R., MD et al

Anesthesia & Analgesia: December 2017 – Volume 125 – Issue 6 – p 1948–1951

This retrospective case series analyzed 45 malpractice claims for delayed detection of esophageal intubation from the Anesthesia Closed Claims Project. Inclusion criteria were cases from 1995 to 2013, after adoption of identification of CO₂ in expired gas to verify correct endotracheal tube position as a monitoring standard by the American Society of Anesthesiologists. Forty-nine percent (95% confidence interval 34%–64%) occurred in the operating room or other anesthesia location where CO₂ detection equipment should have been available. The most common factors contributing to delayed detection were not using, ignoring, or misinterpreting CO₂ readings. Misdiagnosis, as with bronchospasm, occurred in 33% (95% confidence interval 20%)