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Medical-Legal Issues: Staying In the OR Lynn Fitzgerald Macksey RN MSN CRNA and Out of Court.

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Presentation on theme: "Medical-Legal Issues: Staying In the OR Lynn Fitzgerald Macksey RN MSN CRNA and Out of Court."— Presentation transcript:

1 Medical-Legal Issues: Staying In the OR Lynn Fitzgerald Macksey RN MSN CRNA and Out of Court

2 2 Anesthesia…and Medical Malpractice “For some must watch while some may sleep….” - Shakespeare

3 3 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

4 4 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

5 5 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.

6 6 “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.

7 7 Elements of Negligence  Four Elements of Medical Malpractice 1. Duty 2. Breach of duty, i.e., negligence 3. Causal connection 4. Injuries/Damages Without all four of these, negligence cannot be proven.

8 8 #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.

9 9 #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?

10 10 Who decides negligence… or standard of care?  A qualified expert witness speaks to the standard of care.  Opinions are expressed in degrees of likelihood.

11 11 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.

12 12 #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. Causation is most significant element of the case!!!!

13 13 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?!

14 14 Causation Causation is the attorney’s most important element in any malpractice case.

15 15 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: m edication errors, nerve damage

16 16 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.

17 17 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.

18 18 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.

19 19 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

20 20 #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.

21 21 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

22 22 No case is black and white!  The bottom line?  Does the attorney think they can win?  Are all of the elements present?  Is the patient credible?  Are the damages sufficient to justify the expense and time required to prosecute a case?

23 23 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?

24 24 Does the case have merit? Is the outcome someone’s fault? Doesn’t always matter.

25 25 Paramedics

26 26 L&D Nurse Verdict: $9 million

27 27 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

28 28 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

29 29 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.

30 30 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

31 31 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

32 32 It all sounds so obvious…

33 33 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.

34 34 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

35 35 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.

36 Production pressure How can we meet production expectations while minimizing patient safety and professional liability risks - ** Increased communication between ALL providers involved in a patient’s care. ** Maintaining safe practice guidelines.

37 37 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

38 38 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.

39 39 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.

40 40 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!!

41 41 Anesthesia Malpractice Data Closed Claims Data  Closed Claims are medical malpractice claims related to significant anesthesia- related 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.

42 42 Closed Claim Data  1985  ASA started the Closed Claim Project  2001  the AANA published their findings regarding CRNAs involved in closed claims.

43 43 Closed Claim data  This data has led to higher standards of care and mandatory monitoring.

44 Closed Claim Data  Using this information can help to  improve clinical practice  evaluate new therapies  anticipate problems 44

45 45 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.

46 46 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

47 47 Closed Claim Data $34 to $36 million

48 48 Closed Claim Data – top 3 reasons lawsuits are filed #1 lawsuit: (29%) death #2 lawsuit: (19%) peripheral nerve damage #3 lawsuit: (9%) brain damage

49 49 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%)

50 50 Other reasons suits are filed  Wrong drug dose (4%)  Eye injury (3%)  Recall / Awareness (2%)

51 51 Death or Brain damage Death or brain damage was precipitated by respiratory events (45%) and cardiovascular events (25%)

52 52 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

53 53 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

54 54 Respiratory Events  Adverse outcomes associated with respiratory events are the single largest class of serious injury in the ASA Closed Claims Study.

55 55 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%).

56 56 Inadequate ventilation BARNA, ESTATE OF v. HACKENSACKTOWN COMMUNITY HOSPITAL; BODNER, M.D.; MURPHY, M.D.; ET. AL 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

57 57 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.

58 58 Morbidly obese 72-year-old male for Afib ablation Extubated at end of case, tongue noted to be swollen, sats 89% on arrival to PACU. Facemask on 10 liter flow coughing up bloody secretions, right neck and tongue grossly swollen. Sats dropping, multiple physicians called and consulted – 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 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. Verdict: case still in review Lucas; 2011

59 59 Respiratory events  Airway trauma  Larynx (33%)  Pharynx (19%)  Esophagus (18%)  Trachea (14%)  Temporomandibular joint [TMJ] (10%)

60 60 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

61 61 Airway trauma UECK v. BAIDYA, M.D. 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 several unsuccessful intubation attempts using excessive force because of improper equipment.  The defendant maintained the plaintiff's swallowing problems were psychological, unrelated to intubation, that appropriate equipment was used, and that possibility of a perforation is a known risk of the procedure. Verdict: $0

62 62 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.

63 63 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

64 64 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.

65 65 Respiratory events Difficult airway management during perioperative period occurs  Induction 67%  Surgery 15%  Extubation 12%  Recovery 6%

66 66 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.

67 67 Respiratory events In a 2008 case, an 11- month-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

68 Respiratory events Difficult airway algorithm – do you know it? 68

69 69 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

70 70 Respiratory events  Difficult original intubation (4 attempts) with swelling of throat  Trendelenburg position for 7 hours  Known laryngeal polyps  Morbidly obese patient with a large neck

71 71 Respiratory events  Difficult Airway intraoperatively :  Death 46%  Difficult Airway outside the OR  Death 87%

72 72 Respiratory events All adverse respiratory events in PACU are found to be preventable with the use of continuous pulse oximetry.

73 73 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 5- month old who now is in a persistent vegetative state.

74 74 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.

75 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

76 76 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.

77 77 Anesthesia Equipment & Monitors  Misuse of equipment  3x more likely than equipment failure  Mis/disconnects of breathing circuit largest contributor to patient injury  Equipment failure

78 78 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

79 79 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.

80 80 Anesthetic Plan TIPS: Formulate a patient-specific anesthetic plan and discuss with the patient. Document plan discussion.

81 81 Informed Consent  Informed Consent is 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

82 82 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.

83 83 Informed Consent TIPS:  Patients should understand that no anesthetic technique is risk-free.  Protecting yourself comes down to DOCUMENTATION.

84 84 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.

85 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

86 86 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.

87 87 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!

88 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

89 89 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.

90 90 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.

91 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

92 92 Respiratory - monitoring Before capnography- it took > 5 minutes to confirm correct placement of endotracheal tube. With capnography- confirmation occurs within seconds and death / brain damage from esophageal intubation ↓ from 11% to 3% of claims.

93 93 Respiratory - monitoring TIPS: Use Capnography monitoring along with Pulse ox monitoring

94 94 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.

95 95 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.

96 96 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.

97 97 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

98 98 Cardiovascular events  Cardiovascular events occurs most often during.…  maintenance of general anesthesia  > 50% due to blood loss or electrolyte mismanagement.

99 99 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

100 100 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%)

101 101 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.

102 102 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.”

103 103 TIPS: Peripheral nerve damage  Assess and document –  preexisting patient conditions and deficits  positioning  padding

104 104 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. Robert Cormier v. Duane Dixon, M.D.; and Robert Steinberg, M.D. Verdict: $127,500 Both anesthesiologists denied the plaintiff's negligence claims; they stated they acted within the applicable standard of care at all times. Patient was taking Coumadin for a prosthetic heart valve, The anesthesiologists did not determine the patient’s coagulation profile before attempting the block. The patient needed surgery for a hematoma.

105 105 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 !

106 106 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.

107 107 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.

108 108 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

109 109 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

110 110 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.

111 111 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.

112 112 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.

113 113 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.

114 114 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

115 115 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

116 116 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 patient- controlled 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,

117 117 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 follow-up  Insufficient monitoring (i.e. continuous pulse oximeter)

118 118 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??)

119 119 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).

120 120 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.

121 121 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

122 122 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

123 123 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 Britteny And Ariel Lingold, Minors, B/N/F And Natural Father, William Lingold, Jr. V. John Bowden, M.D. And Rockdale Anesthesia

124 124 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

125 125 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

126 126 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

127 127 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.

128 128 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%)

129 129 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

130 130 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

131 131 Eye injury- Postoperative 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.

132 132 Eye injury TIPS:  Maintain mean arterial pressures at > 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.

133 133 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.

134 134 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.

135 135 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.

136 136 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

137 137 Awareness/Recall  Recall claims occurred most often during general anesthesia given to -  Women  Opioids used  Muscle relaxation used  No volatile anesthetic used

138 138 Awareness/Recall TIPS:  Prevent awareness –  Use BIS monitor, maintain between  Monitor for unexpected tachycardia and or hypertension  Monitor volatile anesthetic levels in vaporizers “The most important “monitor” is the anesthesia provider.”

139 139 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.

140 140 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!

141 141 Worst Outcomes in CRNA database Correlated with outcomes  Inappropriate care  Lack of vigilance  Preventable outcomes  Airway incidents Not Correlated  Preop physical status  Patient age  Type of surgery  Age of anesthesia provider  Years of CRNA certification

142 142 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.

143 143 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.

144 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

145 145 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.

146 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

147 147 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.

148 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

149 149 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.

150 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

151 151 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.

152 152 If you do it?

153 153 A huge truth! Good documentation supports your defense… while poor documentation supports the plaintiff’s case.

154 154 Thank you very much! What questions do you have?

155 155 The End

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