Newly Published
Perioperative Medicine  |   May 2017
Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Analysis
Author Notes
  • From the Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, München, Germany (C.M.S., K.J.W.); Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, New Jersey (A.B.); Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington (K.L.P., S.L.M., K.B.D.); and Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles Health System, Los Angeles, California (R.S.).
  • Preliminary findings were presented at the American Society of Anesthesiologists annual meeting in New Orleans, Louisiana, October 14, 2014 (Burden AR, et al.: Situational Awareness Errors in Anesthesia Malpractice Claims. Abstract A4137) and at the American Society of Anesthesiologists annual meeting in Chicago, Illinois, October 24, 2016 (Burden AR, et al.: Situational Awareness Errors in Anesthesia Malpractice Claims: Errors of Perception, Comprehension and Projection Leading to Catastrophic Outcomes. Abstract A3207).
    Preliminary findings were presented at the American Society of Anesthesiologists annual meeting in New Orleans, Louisiana, October 14, 2014 (Burden AR, et al.: Situational Awareness Errors in Anesthesia Malpractice Claims. Abstract A4137) and at the American Society of Anesthesiologists annual meeting in Chicago, Illinois, October 24, 2016 (Burden AR, et al.: Situational Awareness Errors in Anesthesia Malpractice Claims: Errors of Perception, Comprehension and Projection Leading to Catastrophic Outcomes. Abstract A3207).×
  • Submitted for publication June 3, 2016. Accepted for publication March 27, 2017.
    Submitted for publication June 3, 2016. Accepted for publication March 27, 2017.×
  • Acknowledgments: The authors acknowledge the closed claims reviewers from the American Society of Anesthesiologists (Schaumburg, Illinois) and participation of the following liability insurance companies who have given permission to be acknowledged: Anesthesia Service Medical Group, Inc., San Diego, California; COPIC Insurance Company, Denver, Colorado; ISMIE Mutual Insurance Company, Chicago, Illinois; MagMutual Insurance Company, Atlanta, Georgia; Medical Liability Mutual Insurance Company, New York, New York; Midwest Medical Insurance Company, Minneapolis, Minnesota; NORCAL Mutual Insurance Company, San Francisco, California; Physicians Insurance, A Mutual Company, Seattle, Washington; Preferred Physicians Medical Risk Retention Group, Overland Park, Kansas; Risk Management Foundation, Cambridge, Massachusetts; State Volunteer Mutual Insurance Company, Brentwood, Tennessee; The Doctors’ Company, Napa, California; and the University of Texas System, Austin, Texas.
    Acknowledgments: The authors acknowledge the closed claims reviewers from the American Society of Anesthesiologists (Schaumburg, Illinois) and participation of the following liability insurance companies who have given permission to be acknowledged: Anesthesia Service Medical Group, Inc., San Diego, California; COPIC Insurance Company, Denver, Colorado; ISMIE Mutual Insurance Company, Chicago, Illinois; MagMutual Insurance Company, Atlanta, Georgia; Medical Liability Mutual Insurance Company, New York, New York; Midwest Medical Insurance Company, Minneapolis, Minnesota; NORCAL Mutual Insurance Company, San Francisco, California; Physicians Insurance, A Mutual Company, Seattle, Washington; Preferred Physicians Medical Risk Retention Group, Overland Park, Kansas; Risk Management Foundation, Cambridge, Massachusetts; State Volunteer Mutual Insurance Company, Brentwood, Tennessee; The Doctors’ Company, Napa, California; and the University of Texas System, Austin, Texas.×
  • Research Support: Supported in part by the American Society of Anesthesiologists, Schaumburg, Illinois, and the Anesthesia Quality Institute, Schaumburg, Illinois. All opinions expressed are those of the authors and do not reflect the policy of the American Society of Anesthesiologists or Anesthesia Quality Institute. REDCap (Research Electronic Data Capture) electronic data capture tools hosted at the University of Washington, Seattle, Washington, were provided by the Institute of Translational Health Science through grant No. UL1 RR025014 from the National Institutes of Health National Center for Research Resources, Bethesda, Maryland. Additional support was provided by institutional funding.
    Research Support: Supported in part by the American Society of Anesthesiologists, Schaumburg, Illinois, and the Anesthesia Quality Institute, Schaumburg, Illinois. All opinions expressed are those of the authors and do not reflect the policy of the American Society of Anesthesiologists or Anesthesia Quality Institute. REDCap (Research Electronic Data Capture) electronic data capture tools hosted at the University of Washington, Seattle, Washington, were provided by the Institute of Translational Health Science through grant No. UL1 RR025014 from the National Institutes of Health National Center for Research Resources, Bethesda, Maryland. Additional support was provided by institutional funding.×
  • Competing Interests: The authors declare no competing interests.
    Competing Interests: The authors declare no competing interests.×
  • Correspondence: Address correspondence to Dr. Schulz: Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 München, Germany. c.schulz@tum.de. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Central and Peripheral Nervous Systems / Trauma / Burn Care
Perioperative Medicine   |   May 2017
Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Analysis
Anesthesiology Newly Published on May 4, 2017. doi:10.1097/ALN.0000000000001661
Anesthesiology Newly Published on May 4, 2017. doi:10.1097/ALN.0000000000001661
Abstract

Background: Situational awareness errors may play an important role in the genesis of patient harm. The authors examined closed anesthesia malpractice claims for death or brain damage to determine the frequency and type of situational awareness errors.

Methods: Surgical and procedural anesthesia death and brain damage claims in the Anesthesia Closed Claims Project database were analyzed. Situational awareness error was defined as failure to perceive relevant clinical information, failure to comprehend the meaning of available information, or failure to project, anticipate, or plan. Patient and case characteristics, primary damaging events, and anesthesia payments in claims with situational awareness errors were compared to other death and brain damage claims from 2002 to 2013.

Results: Anesthesiologist situational awareness errors contributed to death or brain damage in 198 of 266 claims (74%). Respiratory system damaging events were more common in claims with situational awareness errors (56%) than other claims (21%, P < 0.001). The most common specific respiratory events in error claims were inadequate oxygenation or ventilation (24%), difficult intubation (11%), and aspiration (10%). Payments were made in 85% of situational awareness error claims compared to 46% in other claims (P = 0.001), with no significant difference in payment size. Among 198 claims with anesthesia situational awareness error, perception errors were most common (42%), whereas comprehension errors (29%) and projection errors (29%) were relatively less common.

Conclusions: Situational awareness error definitions were operationalized for reliable application to real-world anesthesia cases. Situational awareness errors may have contributed to catastrophic outcomes in three quarters of recent anesthesia malpractice claims.

Abstract

Situational awareness errors resulting in death or brain damage remain prevalent causes of malpractice claims in the 21st century.