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Pimentel MPT, Chung S, Ross JM, Wright D, Urman RD. Anesthesia-Related Closed Claims in Free-Standing Ambulatory Surgery Centers. Anesth Analg 2024; 139:521-531. [PMID: 38640080 DOI: 10.1213/ane.0000000000006700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
BACKGROUND As higher acuity procedures continue to move from hospital-based operating rooms (HORs) to free-standing ambulatory surgery centers (ASCs), concerns for patient safety remain high. We conducted a contemporary, descriptive analysis of anesthesia-related liability closed claims to understand risks to patient safety in the free-standing ASC setting, compared to HORs. METHODS Free-standing ASC and HOR closed claims between 2015 and 2022 from The Doctors Company that involved an anesthesia provider responsible for the claim were included. We compared the coded data of 212 free-standing ASC claims with 268 HOR claims in terms of severity of injury, major injuries, allegations, comorbidities, contributing factors, and financial value of the claim. RESULTS Free-standing ASC claims accounted for almost half of all anesthesia-related cases (44%, 212 of 480). Claims with high severity of injury were less frequent in free-standing ASCs (22%) compared to HORs (34%; P = .004). The most common types of injuries in both free-standing ASCs and HORs were dental injury (17% vs 17%) and nerve damage (14% vs 11%). No difference in frequency was noted for types of injuries between claims from free-standing ASCs versus HORs--except that burns appeared more frequently in free-standing ASC claims than in HORs (6% vs 2%; P = .015). Claims with alleged improper management of anesthesia occurred less frequently among free-standing ASC claims than HOR claims (17% vs 29%; P = .01), as well as positioning-related injury (3% vs 8%; P = .025). No difference was seen in frequency of claims regarding alleged improper performance of anesthesia procedures between free-standing ASCs and HORs (25% vs 19%; P = .072). Technical performance of procedures (ie, intubation and nerve block) was the most common contributing factor among free-standing ASC (74%) and HOR (74%) claims. Free-standing ASC claims also had a higher frequency of communication issues between provider and patient/family versus HOR claims (20% vs 10%; P = .004). Most claims were not associated with major comorbidities; however, cardiovascular disease was less prevalent in free-standing ASC claims versus HOR claims (3% vs 11%; P = .002). The mean ± standard deviation total of expenses and payments was lower among free-standing ASC claims ($167,000 ± $295,000) than HOR claims ($332,000 ± $775,000; P = .002). CONCLUSIONS This analysis of medical malpractice claims may indicate higher-than-expected patient and procedural complexity in free-standing ASCs, presenting patient safety concerns and opportunities for improvement. Ambulatory anesthesia practices should consider improving safety culture and communication with families while ensuring that providers have up-to-date training and resources to safely perform routine anesthesia procedures.
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Affiliation(s)
- Marc Philip T Pimentel
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott Chung
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline M Ross
- Department of Patient Safety and Risk Management, The Doctors Company, Napa, California
| | - Daniel Wright
- Department of Patient Safety and Risk Management, The Doctors Company, Napa, California
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University, Columbus, Ohio
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Kusumoto F, Ross J, Wright D, Chazal RA, Anderson RE. Analysis of Closed Claims Among All Medical Specialties: Importance of Communication and Other Non-Clinical Contributing Factors. Risk Manag Healthc Policy 2024; 17:411-422. [PMID: 38440254 PMCID: PMC10910983 DOI: 10.2147/rmhp.s403710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/24/2023] [Indexed: 03/06/2024] Open
Abstract
Objective Medical malpractice claims represent patient dissatisfaction of care delivered by their healthcare provider. Evaluation of contributing factors (CFs) associated with claims provides important information to optimize the patient-provider relationship. Study Design A total of 21,101 closed claims with 54,479 CFs (2.2 contributing factors per claim) from a large medical professional liability coverage provider were analyzed from 2010 to 2019. Results Four clinical CFs (technical performance, management of therapy, patient assessment, and patient factors) and four nonclinical CFs (communication between providers and patient, communication among providers, failure or delay in obtaining a consult, and insufficient documentation) were identified >1,500 times. Nonclinical CFs increased as a percentage from 50% in the first part of the study period to 54% in the second part of the study period (p < 0.01), and were more frequent in cases associated with indemnity when compared to clinical CFs (Nonclinical: 57% vs 43%; p < 0.001). Poor communication as a CF increased steadily during the study period (3-year average; 2010-2012: 777 CF/year vs 2017-2019: 1207 CF/year; p < 0.001). In claims associated with high severity injury, poor communication among providers was more significant than poor communication between the provider and patient (63% vs 29%; p < 0.001), mainly due to failure to convey the severity of the patient's condition. For non-surgical specialties except psychiatry, communication was the highest CF and the second or third CF for psychiatry or surgical specialties. Discussion Clinical and nonclinical CFs are equally important for malpractice claims. Communications issues are particularly important regardless of specialty. While focusing on clinical quality is important, implementing strategies that account for nonclinical issues, with a particular focus on communication, would have significant benefits particularly in an environment of increased consolidation of healthcare delivery systems.
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Affiliation(s)
- Fred Kusumoto
- Heart Rhythm Service, Department of Cardiovascular Disease, Mayo Clinic, Jacksonville, FL, USA
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Young S, Osman B, Shapiro FE. Safety considerations with the current ambulatory trends: more complicated procedures and more complicated patients. Korean J Anesthesiol 2023; 76:400-412. [PMID: 36912006 PMCID: PMC10562071 DOI: 10.4097/kja.23078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023] Open
Abstract
In the last quarter of a century, the backdrop of appropriate ambulatory and office-based surgeries has changed dramatically. Procedures that were traditionally done in hospitals or patients being admitted after surgery are migrating to the outpatient setting and being discharged on the same day, respectively, at a remarkable rate. In the face of this exponential growth, anesthesiologists are constantly being challenged to maintain patient safety by understanding the appropriate patient selection, procedure, and surgical location. Recently published literature supports the trend of higher, more medically complex patients, and more complicated procedures shifting towards the outpatient arena. Several reasons that may account for this include cost incentives, advancement in anesthesia techniques, enhanced recovery after surgery (ERAS) protocols, and increased patient satisfaction. Anesthesiologists must understand that there is a lack of standardized state regulations regarding ambulatory surgery centers (ASCs) and office-based surgery (OBS) centers. Current and recently graduated anesthesiologists should be aware of the safety concerns related to the various non-hospital-based locations, the sustained growth and demand for anesthesia in the office, and the expansion of mobile anesthesia practices in the US in order to keep up and practice safely with the professional trends. Continuing procedural ambulatory shifts will require ongoing outcomes research, likely prospective in nature, on these novel outpatient procedures, in order to develop risk stratification and prediction models for the selection of the proper patient, procedure, and surgery location.
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Affiliation(s)
- Steven Young
- Department of Anesthesiology, 1Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Brian Osman
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Fred E. Shapiro
- Department of Anesthesiology, 1Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW Ambulatory surgery is increasingly performed in medically complex patients. This dynamic environment requires new approaches to ensure cost-effective, efficient, and ultimately safe preoperative evaluation of the patient. This review investigates recent advances in the assessment of ambulatory patients, with a special focus on patient screening, digital communication, and multidisciplinary team evaluation. RECENT FINDINGS Identifying suitable candidates for ambulatory surgery relies on a variety of medical, surgical, and institutional factors. Identification of high-risk patients and optimization of their treatment can be achieved through multidisciplinary protocols specific to the local institution and in line with current guidelines. Virtual assessment may be sufficient for most patients and provide an efficient evaluation strategy and high patient satisfaction. Prescreening can be supported by preoperative nursing teams. SUMMARY The increasing complexity of treatment provided in day surgery offers a unique opportunity to highlight the importance of anesthesiology staff as perioperative caregivers. Preoperative evaluation serves as a central junction to integrate a variety of surgical, medical, and institutional factors to provide safe, satisfactory, and efficient care for patients. Implementing technological innovation to streamline and facilitate this process is paramount.
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What we can learn from nonoperating room anesthesia registries: analysis of clinical outcomes and closed claims data. Curr Opin Anaesthesiol 2020; 33:527-532. [DOI: 10.1097/aco.0000000000000844] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The association of body mass index with same-day hospital admission, postoperative complications, and 30-day readmission following day-case eligible joint arthroscopy: A national registry analysis. J Clin Anesth 2020; 59:26-31. [DOI: 10.1016/j.jclinane.2019.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/08/2019] [Accepted: 06/02/2019] [Indexed: 11/19/2022]
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Clapper TC, Ching K. Debunking the myth that the majority of medical errors are attributed to communication. MEDICAL EDUCATION 2020; 54:74-81. [PMID: 31509277 DOI: 10.1111/medu.13821] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 10/10/2018] [Accepted: 01/10/2019] [Indexed: 06/10/2023]
Abstract
CONTEXT Many articles, book chapters and presentations begin with a declaration that the majority of medical errors are attributed to communication. However, this statement may not be supported by the research reported in the literature. OBJECTIVES The purpose of this systematic review is to identify where errors are reported in the research literature. METHODS A systematised review was conducted of research articles over the last 20 years (1998-2018) indexed in PubMed/MEDLINE and the Cumulative Index to Nursing and Allied Health (CINAHL) using term combinations: medical errors, research and communication. Inclusion was based on reported generalised primary research of medical error and the reported causes. RESULTS This systematised review resulted in 2881 research articles, which produced 42 that met the inclusion criteria. Although there was some overlap, three categories of errors were dominant in this research: errors of commission (20 articles; 47.6%), errors of omission (six articles; 14.2%) and errors through communication (four articles; 9.5%). There were 12 (28.5%) articles in which all three categories together significantly contributed to error. Of these 12 articles, errors of commission or omission were dominant in nine articles (21.4%) and errors of communication were prevalent in only three articles (7%). CONCLUSIONS The assertion that the majority of medical errors can be attributed to miscommunication is not supported by this systematic review. Overwhelmingly, most reported errors are attributed to errors of omission or commission. Intentionally or unintentionally providing misinformation may mislead patient safety initiatives, and research and funding agency priorities.
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Affiliation(s)
- Timothy C Clapper
- Weill Cornell Medicine New York-Presbyterian Simulation Program and Center, Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Kevin Ching
- Weill Cornell Medicine New York-Presbyterian Simulation Program and Center, Department of Pediatrics, Weill Cornell Medical College, New York, New York
- Department of Emergency Medicine, Weill Cornell Medical College, New York, New York
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Abstract
Dental injury is a common cause of malpractice claims involving anesthesiologists. Inadequate preoperative dental evaluations and incomplete documentation are often cited as contributing factors during reviews of closed claims. Point-of-care smartphone photographs are widely used in other medical fields such as dermatology and plastic surgery. We discuss the use of smartphone photographs for documenting preoperative dental examinations.
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Affiliation(s)
- Alexander B Stone
- From the Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Guertin M, Heard J, Del Rosario T. Ambulatory Surgery Center Medical Director: Visionary Leader. Anesthesiol Clin 2019; 37:389-400. [PMID: 31047137 DOI: 10.1016/j.anclin.2019.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The ambulatory surgery center medical director is a physician leader who recognizes the need to develop a culture that encourages communication and empowerment of employees and professional staff, leading to engagement that optimize care through patient selection, safety and satisfaction requires vision and guidance from the medical director and is central to success of the ASC. Innovative thinking further improves patient care and long-term success by leveraging advances in technology and sustainable practices.
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Affiliation(s)
- Michael Guertin
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Jameson Crane Sports Medicine Institute, 2835 Fred Taylor Drive, Office 2214, Columbus, OH 43202, USA.
| | - Jarrett Heard
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, N410 Doan Hall, Columbus, OH 43210, USA
| | - Timothy Del Rosario
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, N410 Doan Hall, Columbus, OH 43210, USA
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Abstract
PURPOSE OF REVIEW This review summarizes and discusses the history of continuous catheter blockade (CCB), its current applications, clinical considerations, economic benefits, potential complications, patient education, and best practice techniques. RECENT FINDINGS Regional catheters for outpatient surgery have greatly impacted acute post-operative pain management and recovery. Prior to development, options for acute pain management were limited to the use of opioid pain medications, NSAIDS, neuropathic agents, and the like as local anesthetic duration of action is limited to 4-8 h. Moreover, delivery of opioids post-operatively has been associated with respiratory and central nervous depression, development of opioid use disorder, and many other potential adverse effects. CCB allows for faster recovery time, decreased rates of opioid abuse, and better pain control in patients post-operatively. Outpatient surgical settings continue to focus on efficiency, quality, and safety, including strategies to prevent post-operative nausea, vomiting, and pain. Regional catheters are a valuable tool and help achieve all of the well-established endpoints of enhanced recovery after surgery (ERAS). CCB is growing in popularity with wide indications for a variety of surgeries, and has demonstrated improved patient satisfaction, outcomes, and reductions in many unwanted adverse effects in the outpatient setting.
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Mora JC, Kaye AD, Romankowski ML, Delahoussaye PJ, Urman RD, Przkora R. Trends in Anesthesia-Related Liability and Lessons Learned. Adv Anesth 2018; 36:231-249. [PMID: 30414640 DOI: 10.1016/j.aan.2018.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Juan C Mora
- Department of Anesthesiology, Division of Pain Medicine, University of Florida, PO Box 100254, Room 2036, Gainesville, FL 32610-0254, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Room 656, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Matthew L Romankowski
- Department of Anesthesiology, Division of Pain Medicine, University of Florida, PO Box 100254, Room 2036, Gainesville, FL 32610-0254, USA
| | - Paul J Delahoussaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Room 659, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Rene Przkora
- Department of Anesthesiology, Division of Pain Medicine, Multidisciplinary Pain Medicine Fellowship, Anesthesiology Residency, University of Florida, PO Box 100254, Room 2036, Gainesville, FL 32610-0254, USA.
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Lee JW. Considerations in treating obese patients in office-based anesthesia. Minerva Anestesiol 2018; 84:1318-1322. [DOI: 10.23736/s0375-9393.18.12670-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Berglas NF, Battistelli MF, Nicholson WK, Sobota M, Urman RD, Roberts SCM. The effect of facility characteristics on patient safety, patient experience, and service availability for procedures in non-hospital-affiliated outpatient settings: A systematic review. PLoS One 2018; 13:e0190975. [PMID: 29304180 PMCID: PMC5755935 DOI: 10.1371/journal.pone.0190975] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 12/23/2017] [Indexed: 11/27/2022] Open
Abstract
Background Over recent decades, numerous medical procedures have migrated out of hospitals and into freestanding ambulatory surgery centers (ASCs) and physician offices, with possible implications for patient outcomes. In response, states have passed regulations for office-based surgeries, private organizations have established standards for facility accreditation, and professional associations have developed clinical guidelines. While abortions have been performed in office setting for decades, states have also enacted laws requiring that facilities that perform abortions meet specific requirements. The extent to which facility requirements have an impact on patient outcomes—for any procedure—is unclear. Methods and findings We conducted a systematic review to examine the effect of outpatient facility type (ASC vs. office) and specific facility characteristics (e.g., facility accreditation, emergency response protocols, clinician qualifications, physical plant characteristics, other policies) on patient safety, patient experience and service availability in non-hospital-affiliated outpatient settings. To identify relevant research, we searched databases of the published academic literature (PubMed, EMBASE, Web of Science) and websites of governmental and non-governmental organizations. Two investigators reviewed 3049 abstracts and full-text articles against inclusion/exclusion criteria and assessed the quality of 22 identified articles. Most studies were hampered by methodological challenges, with 12 of 22 not meeting minimum quality criteria. Of 10 studies included in the review, most (6) examined the effect of facility type on patient safety. Existing research appears to indicate no difference in patient safety for outpatient procedures performed in ASCs vs. physician offices. Research about specific facility characteristics is insufficient to draw conclusions. Conclusions More and higher quality research is needed to determine if there is a public health problem to be addressed through facility regulation and, if so, which facility characteristics may result in consistent improvements to patient safety while not adversely affecting patient experience or service availability.
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Affiliation(s)
- Nancy F. Berglas
- Advancing New Standards in Reproductive Health, University of California, San Francisco (UCSF), Oakland, California, United States of America
- * E-mail:
| | - Molly F. Battistelli
- Advancing New Standards in Reproductive Health, University of California, San Francisco (UCSF), Oakland, California, United States of America
| | - Wanda K. Nicholson
- University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Mindy Sobota
- Rhode Island Hospital, Alpert Medical School at Brown University, Providence, Rhode Island, United States of America
| | - Richard D. Urman
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Sarah C. M. Roberts
- Advancing New Standards in Reproductive Health, University of California, San Francisco (UCSF), Oakland, California, United States of America
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