title: Injury and liability associated with monitored anesthesia care: a closed claims analysis.
abstract: BACKGROUND
  To assess the patterns of injury and liability associated with monitored anesthesia care (MAC) compared with general and regional anesthesia, the authors reviewed closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1990.
  
  
  METHODS
  All surgical anesthesia claims associated with MAC (n = 121) were compared with those associated with general (n = 1,519) and regional (n = 312) anesthesia. A detailed analysis of MAC claims was performed to identify causative mechanisms and liability patterns.
  
  
  RESULTS
  MAC claims involved older and sicker patients compared with general anesthesia claims (P < 0.025), often undergoing elective eye surgery (21%) or facial plastic surgery (26%). More than 40% of claims associated with MAC involved death or permanent brain damage, similar to general anesthesia claims. In contrast, the proportion of regional anesthesia claims with death or permanent brain damage was less (P < 0.01). Respiratory depression, after absolute or relative overdose of sedative or opioid drugs, was the most common (21%, n = 25) specific damaging mechanism in MAC claims. Nearly half of these claims were judged as preventable by better monitoring, including capnography, improved vigilance, or audible alarms. On-the-patient operating room fires, from the use of electrocautery, in the presence of supplemental oxygen during facial surgery, resulted in burn injuries in 20 MAC claims (17%).
  
  
  CONCLUSIONS
  Oversedation leading to respiratory depression was an important mechanism of patient injuries during MAC. Appropriate use of monitoring, vigilance, and early resuscitation could have prevented many of these injuries. Awareness and avoidance of the fire triad (oxidizer, fuel, and ignition source) is essential to prevent on-the-patient fires.
authors.affiliation: Department of Anesthesiology, University of Washington, Virginia Mason Medical Center, Seattle, WA 98195, USA. sbhanank@u.washington.edu
authors.forename: Sanjay M
authors.initials: SM
authors.lastname: Bhananker
authors.forename: Karen L
authors.initials: KL
authors.lastname: Posner
authors.forename: Frederick W
authors.initials: FW
authors.lastname: Cheney
authors.forename: Robert A
authors.initials: RA
authors.lastname: Caplan
authors.forename: Lorri A
authors.initials: LA
authors.lastname: Lee
authors.forename: Karen B
authors.initials: KB
authors.lastname: Domino
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000758:Anesthesia / Q000009:adverse effects*; D000765:Anesthesia, Conduction / Q000009:adverse effects; D000768:Anesthesia, General / Q000009:adverse effects; D000776:Anesthesiology / Q000331:legislation & jurisprudence*; D002056:Burns; D003625:Data Collection; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007345:Insurance Claim Review; D008297:Male; D008318:Malpractice / Q000331:legislation & jurisprudence*; D008875:Middle Aged; D008991:Monitoring, Physiologic; D012131:Respiratory Insufficiency / Q000139:chemically induced; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000209:etiology*