One-Fifth of Anesthesia Malpractice Claims Are for Failure to Rescue

Karen B. Domino, MD, MPH

New research has highlighted the importance that failure to rescue plays in anesthesia malpractice claims with high-severity outcomes.

A study by Karen B. Domino, MD, MPH, and her colleagues at the University of Washington School of Medicine, in Seattle, has found that nearly 20% of claims for severe adverse events were associated with failure to rescue after postoperative patient deterioration.

“Failure to rescue is an issue that contributes significantly to surgical mortality,” said Domino, a professor of anesthesiology and pain medicine at the university. “Since anesthesiologists provide postoperative management and critical care, anesthesia care may be a factor in these events.”

To explore this further, Domino and her colleagues turned to the Anesthesia Quality Institute/American Society of Anesthesiologists Anesthesia Closed Claims Project database. In doing so, their goal was to study clinical factors associated with postoperative deterioration resulting in permanent disabling outcomes or death.

As part of that analysis, the researchers had two primary inclusion criteria:

1. patients who sustained permanent disabling outcomes or death (Injury Severity Score, 6-9) after anesthesia for surgical, obstetric or non-OR procedures; and
2. event occurrence after 2005, which includes 11,034 claims.

Failure-to-rescue claims were defined as “deterioration events” occurring either in the PACU after the first hour of care, on the ward or in the ICU. These events were then compared with other high-severity events occurring during all other phases of anesthesia care, which served as the study’s comparison group.

Figure. Site of failure-to-rescue events.

In a presentation during the virtual Euroanaesthesia 2020 (abstract 5209), Domino revealed that a total of 127 failure-to-rescue claims were included in the analysis. Of those, damaging events occurred most frequently on the ward (n=69; 54%), followed by the ICU (n=39; 31%) and PACU (n=19; 15%; Figure).

Compared with the 584 high-severity-claim patients who served as the comparison group, failure-to-rescue patients were sicker (ASA physical status III-V: 70% vs. 60% in the comparison group; P=0.044) and more often underwent orthopedic surgical procedures (35% vs. 25%, respectively; P=0.020).

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The study also found that inadequate ventilation/oxygenation, excessive blood loss, epidural/spinal hematoma and patient condition were more frequent damaging events in the failure-to-rescue claims than in the comparator group (Table).

Table. Specific Damaging Events In Failure-to-Rescue Claims
Event	Failure-to-Rescue Group	Comparator Group
Inadequate ventilation/oxygenation, %	18	12
Patient condition, %	12	5
Excessive blood loss, %	11	5
Epidural or spinal hematoma, %	8	1

Of note, age, sex, obesity, emergency procedures and severity of injury were not found to be significantly different between the two groups.

“What’s interesting is that these failure-to-rescue events comprise a significant component of adverse events during anesthesia care,” Domino said in an interview with Anesthesiology News. “While it may not be particularly surprising, we feel it’s unique in that these events occur outside the operating room.”

As Domino discussed, the types of damaging events involved in failure-to-rescue anesthesia malpractice claims highlight the importance of timely recognition and treatment of postoperative respiratory depression, postoperative surgical bleeding, epidural/spinal hematoma and patient comorbidities to improve surgical patient safety.

“Many of these adverse events occur during handover and transfers of care to other providers,” she explained. “Therefore, improved communication with the surgical and postoperative teams is critical.”

An example of this, she said, is respiratory depression, which may occur as a result of postoperative pain medication. “This is certainly something that an anesthesia professional should talk to the surgical team or hospitalist about, to remind them of that potential risk with multiple practitioners ordering pain and sedative medication.”

Although these are preliminary findings, Domino explained that the research is ongoing.

“Our plan is to query another three years of data in the Anesthesia Closed Claims [Project] database to do an in-depth analysis of the adverse events from the claim summaries,” she said. “This qualitative analysis will help us find out why the adverse events occurred, and hopefully come up with some potential solutions. After all, the ultimate goal with postoperative care is to be able to adequately treat these complications, and then rescue the patient from having an adverse event.”

Consider Clinician Harm as Well

Marjorie P. Stiegler, MD, the director of social media and digital strategy for the Anesthesia Patient Safety Foundation and an adjunct professor of anesthesiology at the University of North Carolina at Chapel Hill, called the work an important contribution to the literature. “These results are unfortunately not surprising, and certainly underscore the importance of clear communication, especially when transferring care to other teams of clinicians, as well as the importance of continued vigilance in postoperative settings.

“Failure to rescue is clearly an important patient safety issue,” continued Stiegler, who is a member of the Anesthesiology News editorial advisory board. “In addition to the obvious risk of patient harm from failure-to-rescue events, there are considerable ramifications for clinician liability. Because capable and well-intended clinicians may suffer emotionally and psychologically from being involved in cases in which patients suffer harm or death, there are multifaceted reasons to focus on meaningful solutions.”

—Michael Vlessides

Domino and Stiegler reported no relevant financial disclosures.