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Medical-Legal Issues: Staying In the OR

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Title: PowerPoint Presentation Author: Lynn F Macksey Last modified by: Keith Macksey Created Date: 4/5/2013 4:17:52 PM Document presentation format – PowerPoint PPT presentation

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Title: Medical-Legal Issues: Staying In the OR


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

2
Anesthesiaand Medical Malpractice
  • For some must watch while some
    may sleep.
  • - Shakespeare

3
Anesthesiaand 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
MEDICAL MALPRACTICE CASES
  • Criminal
  • Usually not for medical cases unless its a crime
    against society
  • Punishment includes incarceration and punitive
    damages
  • Civil
  • Tort Law
  • Medical malpractice / negligence

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
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
Elements of Negligence
  • Four Elements of Medical Malpractice
  • Duty
  • Breach of duty, i.e., negligence
  • Causal connection
  • Injuries/Damages
  • Without all four of these,
  • negligence cannot be proven.

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 dutythere is no case.

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
Who decides negligenceor standard of care?
  • A qualified expert witness speaks to the standard
    of care.
  • Opinions are expressed in degrees of likelihood.

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
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.

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
Causation
  • Causation is the attorneys most
    important element in any
    malpractice case.

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 medication errors, nerve damage

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 hadnt been for the conduct of the
    defendant, the patient would not have been
    injured.

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
    CRNAs negligence.

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 plaintiffs injury.
  • 3 the injury could not have resulted from
    anything the plaintiff voluntarily did.

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 -
    ordinarily, the court presumes the defendant used
    ordinary care until the plaintiff proves
    otherwise.

20
4 Damages
  • Plaintiffs must show they suffered some type of
    damage and because of the injury, they are
    entitled to monetary compensation.
  • The plaintiffs attorney has the burden of proof.

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
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
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
Does the case have merit?
  • Is the outcome someones fault?
  • Doesnt always matter.

25
Paramedics
26
LD Nurse
Verdict 9 million
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
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
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 patients 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
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
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
It all sounds so obvious
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
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
Production pressure
  • Legal verdicts increasingly address premature
    extubation as an important plaintiffs
    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 -

Maintaining safe
practice guidelines.
Increased communication between ALL providers
involved in a patients care.
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
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
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
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
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
Closed Claim Data
  • 1985
  • ASA started the Closed Claim Project
  • 2001
  • the AANA published their findings regarding CRNAs
    involved in closed claims.

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

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
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 gt males
  • 50 of claims involve obese patients

47
Closed Claim Data
32 million
34 to
http//depts.washington.edu/asaccp/sites/default/f
iles/pdf/Click20here20for20_12.pdf
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
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
Other reasons suits are filed
  • Wrong drug dose (4)
  • Eye injury (3)
  • Recall / Awareness (2)

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

52
Undisclosed settlement in childs death
  • A 6-year-old child received general anesthesia
    for a dental restoration procedure. His only
    history was mild asthma.
  • After extubation, the childs 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 childs 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
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
Respiratory Events
  • Adverse outcomes associated with respiratory
    events are the single largest class of serious
    injury in the ASA Closed Claims Study.

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
Inadequate ventilation
  • 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

BARNA, ESTATE OF v. HACKENSACKTOWN COMMUNITY
HOSPITAL BODNER, M.D. MURPHY, M.D. ET. AL
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
Morbidly obese 72-year-old male for Afib ablation
  • 1205 - Extubated at end of case, tongue noted to
    be swollen, sats 89 on arrival to PACU.
    Facemask on 10 liter flow.
  • 1253 - coughing up bloody secretions, right neck
    and tongue grossly swollen. Sats dropping,
    multiple physicians called and consulted.
  • 1425 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.
  • 1437 - 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
Respiratory events
  • Airway trauma
  • Larynx (33)
  • Pharynx (19)
  • Esophagus (18)
  • Trachea (14)
  • Temporomandibular joint TMJ (10)

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
Airway trauma
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
UECK v. BAIDYA, M.D.
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
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 patients
    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
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
Respiratory events
  • Difficult airway management during perioperative
    period occurs
  • Induction 67
  • Surgery 15
  • Extubation 12
  • Recovery 6

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
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?

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
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
Respiratory events
  • Difficult Airway intraoperatively
  • Death 46
  • Difficult Airway outside the OR
  • Death 87

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

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
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

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

81
Informed Consent
  • Informed Consent was 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
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
Informed Consent
  • TIPS
  • Patients should understand that no anesthetic
    technique is risk-free.
  • Protecting yourself comes down to DOCUMENTATION.

84
Preanesthetic Assessment
  • A cursory review of a patients 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?

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
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.

89
Respiratory - perioperative
  • TIPS
  • Good preoperative airway assessment
  • Have all emergency airway equipment available for
    any suspect airwaysambu, 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
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?

92
Respiratory - monitoring
  • Before capnography-
  • it took gt 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
Respiratory - monitoring
  • TIPS
  • Use
  • Capnography monitoring
  • along with
  • Pulse ox monitoring

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
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 distendedkeep head
    of bed up until stomach can be drained.

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
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
Cardiovascular events
  • Cardiovascular events occurs most often during.
  • maintenance of general anesthesia
  • gt 50 due to blood loss or
  • electrolyte mismanagement.

99
Cardiovascular
  • TIPS
  • All patients get pre-induction EKG print
    out a strip, note ST values
  • Patients history worrisome?
  • Perioperatively, monitor ST segment changes,
    electrolytes, labs, ABGs
  • Keep up with blood losses
  • Treat electrolyte imbalances

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
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
TIPS Peripheral nerve damage
  • Meticulous positioning and padding in all
    patients.
  • Supine position - document bilateral shoulders lt
    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 lt
    90º. Eyes and nose checked q15.

103
TIPS Peripheral nerve damage
  • Assess and document
  • preexisting patient conditions and deficits
  • positioning
  • padding

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.

Patient was taking Coumadin for a prosthetic
heart valve, The anesthesiologists did not
determine the patients coagulation profile
before attempting the block. The patient needed
surgery for a hematoma.
Both anesthesiologists denied the plaintiff's
negligence claims they stated they acted within
the applicable standard of care at all times.
Verdict 127,500
Robert Cormier v. Duane Dixon, M.D. and Robert
Steinberg, M.D.
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
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
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
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
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
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
Wrong drug or wrong dose
  • TIPS
  • Dont 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
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
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
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
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
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
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
Acute Chronic pain care
  • TIPS
  • Continuous oxygen monitoring for patients
    receiving PCA or epidural anesthesia.
  • Intermittent but frequent neurologic monitoring.
  • Have narcan readily available.
  • Patients with OSA may require a higher level of
    monitoringpossibly treated with CPAP?
  • Have both capnography and pulse ox monitors on
    high risk patients at all times! (all
    patients??)

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
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
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
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
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 mothers 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
Spinal vs. epidural - death
  • 25 year old female was in labor with her second
    child. Defendant anesthesiologist administered an
    epidural at the patients 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
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
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
    patients vital signs and ability to communicate
    verbally

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
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
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 patients throat
    and face.
  • Verdict 250,000

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
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
Eye injury
  • TIPS
  • Maintain mean arterial pressures at gt 60-70 mm Hg
    especially for patient in prone or sitting
    positions.
  • Maintain hemoglobin gt 9.4
  • Keep neck in midline to prevent venous congestion
    in the head.
  • Normothermia, euglycemia, and urinary output
    gt 0.5 mL/kg/hr.
  • Chart eyes and nose check along with vital
    signs on anesthesia record in any patient in
    prone position.

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
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
Peripheral IV
  • TIPS
  • Especially with caustic or vasoactive additives
    in solutioncan cause tissue destruction.
    Certain drugs should only be given by central
    line.
  • Questionable PIV?taped securely, ability to
    check during surgerydont just force fluid
    through.
  • Have multiple PIV when arms are tucked and cant
    get to them during surgery.

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

138
Awareness/Recall
  • TIPS
  • Prevent awareness
  • Use BIS monitor, maintain between 40-60
  • Monitor for unexpected tachycardia and or
    hypertension
  • Monitor volatile anesthetic levels in vaporizers

The most important monitor
is the anesthesia provider.
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
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
Worst Outcomes in CRNA database
  • Not Correlated
  • Preop physical status
  • Patient age
  • Type of surgery
  • Age of anesthesia provider
  • Years of CRNA certification
  • Correlated with outcomes
  • Inappropriate care
  • Lack of vigilance
  • Preventable outcomes
  • Airway incidents

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
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 (bougies, Glidescope,
    etc.)

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 patients 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?

147
How to help avoid patient injury and being named
in a lawsuit
  • Address specific risks based on patients
    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 patients history and allergies before
    starting drug or drip.

149
How to help avoid patient injury and being named
in a lawsuit
  • Monitor the patients physiologic condition as
    appropriate for the anesthetic.
  • Implement and adjust the anesthetic based on the
    patients physiologic response.
  • Monitoring includes patient position.

150
How to help avoid patient injury and being named
in a lawsuit
  • Dont just extubate a patient at the end of the
    case!
  • Any question of fluid overload, assess the
    patients ability to breathe around the ETT.

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
If you do it?
153
A huge truth!
  • Good documentation supports your defense
  • while poor documentation supports the
    plaintiffs case.

154
Thank you very much!
What questions do you have?
155
The End
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