Claims for compensation after injuries related to airway management: a nationwide study covering 15 years

Adverse outcomes associated with respiratory events constitute the single largest class of injury in the American Society of Anesthesiology Closed Claims Study (522 of 1541 cases; 34%). Death or brain damage occurred in 85% of cases. The median cost of settlement or jury award was +200,000. Most outcomes (72%) were considered preventable with better monitoring. Three mechanisms of injury accounted for three-fourths of the adverse respiratory events: inadequate ventilation (196; 38%), esophageal intubation (94; 18%), and difficult tracheal intubation (87; 17%). Inadequate ventilation was used to describe claims in which it was evident that insufficient gas exchange had produced the adverse outcome, but it was not possible to identify the exact cause. This group was characterized by the highest proportion of cases in which care was considered substandard (90%). The esophageal intubation group was notable for a recurring diagnostic failure: in 48% of cases where auscultation of breath sounds was performed and documented, this test led to the erroneous conclusion that the endotracheal tube was correctly located in the trachea. Claims for difficult tracheal intubation were distinguished by a comparatively small proportion of cases (36%) in which the outcome was considered preventable with better monitoring. A better understanding of respiratory risks may require investigative protocols that initiate data collection immediately upon the recognition of a critical incident or adverse outcome.

The purpose of this study was to describe methods, risk factors, and outcomes of airway management in all patients (obstetrics excluded) attended by anaesthetists over 27 months. Preoperatively, anaesthetists recorded patient factors and assessed four airway characteristics. Methods of tracheal intubation and ease of direct laryngoscopy following general anaesthesia (easy, awkward, difficult) were noted. Factors predictive of poor outcome and the value of the preoperative airway examination were determined. For 18,205 patients following a direct laryngoscopy, (GA), tracheal intubation was difficult (> 2 laryngoscopies) in 1.8% and awkward ( 200 mm Hg) and dental damage on induction of anaesthesia. It is concluded that difficult tracheal intubations occurred infrequently but were associated with increased morbidity. Patient factors and four physical airway characteristics were useful predictors but limited in identifying all problems.

By matching the medical records of a random sample of 31,429 patients hospitalized in New York State in 1984 with statewide data on medical-malpractice claims, we identified patients who had filed claims against physicians and hospitals. These results were then compared with our findings, based on a review of the same medical records, regarding the incidence of injuries to patients caused by medical management (adverse events). We identified 47 malpractice claims among 30,195 patients' records located on our initial visits to the hospitals, and 4 claims among 580 additional records located during follow-up visits. The overall rate of claims per discharge (weighted) was 0.13 percent (95 percent confidence interval, 0.076 to 0.18 percent). Of the 280 patients who had adverse events caused by medical negligence as defined by the study protocol, 8 filed malpractice claims (weighted rate, 1.53 percent; 95 percent confidence interval, 0 to 3.2 percent). By contrast, our estimate of the statewide ratio of adverse events caused by negligence (27,179) to malpractice claims (3570) is 7.6 to 1. This relative frequency overstates the chances that a negligent adverse event will produce a claim, however, because most of the events for which claims were made in the sample did not meet our definition of adverse events due to negligence. Medical-malpractice litigation infrequently compensates patients injured by medical negligence and rarely identifies, and holds providers accountable for, substandard care.