The impact of closed claims analysis in anesthesiology

The Closed Claims Project was started in 1985 by the American Society of Anesthesiologists (ASA) as part of a series of initiatives directed at improving the safety of patients undergoing anesthesia and surgery. The specific idea was that rising malpractice insurance costs could be reduced, first, by identifying the scope and causes of significant anesthesia-related patient injuries and, second, by making changes in practice. Over the past 30 years, the Project has successfully contributed to improvements in anesthesia patient safety, and malpractice insurance premiums for anesthesiologists have been substantially reduced. Detailed analysis of adverse outcomes with common patterns has provided valuable insights into important patient risk and safety problems. Discovery of recurrent trends has generated safety and education programs aimed to improve patient safety and the quality of anesthetic care.

Data collection and limitations

The database is a structured collection of adverse anesthetic outcomes from the closed claims files of medical liability insurance companies, which insure more than one third of anesthesiologists in the United States. Volunteer ASA members travel to participating medical liability insurance companies to review medical records, depositions, and analyses of closed malpractice claims against anesthesiologists. Clinical data (e.g., patient demographics, procedure, anesthetic technique, type and severity of injury, sequence of events leading to injury, and a detailed summary) as well as liability data (e.g., standard of care, claim resolution, and claim settlement) are collected. Claims for dental injury, the most common claim against anesthesiologists, are not included in the database.

It is important to remember that data concerning how many and what types of anesthetic agents and techniques have been administered by anesthesiologists insured by the companies are not known. Hence, relative risks of a particular anesthetic technique cannot be determined by the Closed Claims Project. The database consists of only claims against anesthesiologists, not other anesthesia providers or medical specialists, unless the provider or specialist worked with the anesthesiologist. In addition, malpractice claims are estimated to represent only 3% to 4% of all patient injuries due to negligence. Because the U.S. medical liability system is a tort-based system with plaintiff payment contingent upon a successful lawsuit, the database is biased for severe injuries that occurred in patients who received substandard care. However, the database does contain a wealth of clinical details of rare, severe, adverse outcomes, and it provides a snapshot of liability in the United States.

Overview of adverse outcomes and their causes

The database currently contains almost 10,000 claims. The three major adverse outcomes in the database are death (29%); nerve damage (peripheral nerve or spinal cord, 19%) or brain damage (10%); and all other complications (e.g., airway trauma, stroke, myocardial infarction), account for the remaining 42% of claims (Figure 238-1). Although various media outlets have given extensive coverage to the topic of awareness during anesthesia, awareness represents only 2% of the claims in the database and, hence, is not currently a major medicolegal risk in the United States.

The types of complications that are listed in the database vary with the type of anesthesia used (Figure 238-2