title: Massive hemorrhage: a report from the anesthesia closed claims project.
abstract: BACKGROUND
  Hemorrhage is a potentially preventable cause of adverse outcomes in surgical and obstetric patients. New understanding of the pathophysiology of hemorrhagic shock, including development of coagulopathy, has led to evolution of recommendations for treatment. However, no recent study has examined the legal outcomes of these claims. The authors reviewed closed anesthesia malpractice claims related to hemorrhage, seeking common factors to guide future management strategies.
  
  
  METHODS
  The authors analyzed 3,211 closed surgical or obstetric anesthesia malpractice claims from 1995 to 2011 in the Anesthesia Closed Claims Project. Claims where patient injury was attributed to hemorrhage were compared with all other surgical and obstetric claims. Risk factors for hemorrhage and coagulopathy, clinical factors, management, and communication issues were abstracted from claim narratives to identify recurrent patterns.
  
  
  RESULTS
  Hemorrhage occurred in 141 (4%) claims. Obstetrics accounted for 30% of hemorrhage claims compared with 13% of nonhemorrhage claims (P < 0.001); thoracic or lumbar spine surgery was similarly overrepresented (24 vs. 6%, P < 0.001). Mortality was higher in hemorrhage than nonhemorrhage claims (77 vs. 27%, P < 0.001), and anesthesia care was more often judged to be less than appropriate (55 vs. 38%, P < 0.001). Median payments were higher in hemorrhage versus nonhemorrhage claims ($607,750 vs. $276,000, P < 0.001). Risk factors for hemorrhage and coagulopathy were common, and initiation of transfusion therapy was commonly delayed.
  
  
  CONCLUSIONS
  Hemorrhage is a rare, but serious, cause of anesthesia malpractice claims. Understanding which patients are at risk can aid in patient referral decisions, design of institutional systems for responding to hemorrhage, and education of surgeons, obstetricians, and anesthesiologists.
authors.affiliation: From the Anesthesia Quality Institute, Park Ridge, Illinois, and Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois (R.P.D.); Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee (L.A.L.); and Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington (L.S.S., K.L.P., J.M.D., K.B.D.).
authors.forename: Richard P
authors.initials: RP
authors.lastname: Dutton
authors.forename: Lorri A
authors.initials: LA
authors.lastname: Lee
authors.forename: Linda S
authors.initials: LS
authors.lastname: Stephens
authors.forename: Karen L
authors.initials: KL
authors.lastname: Posner
authors.forename: Joanna M
authors.initials: JM
authors.lastname: Davies
authors.forename: Karen B
authors.initials: KB
authors.lastname: Domino
mesh_terms: D000773:Anesthesia, Obstetrical; D000776:Anesthesiology / Q000331:legislation & jurisprudence*; D016063:Blood Loss, Surgical; D001803:Blood Transfusion; D006801:Humans; D008318:Malpractice / Q000331:legislation & jurisprudence; D006473:Postpartum Hemorrhage / Q000175:diagnosis / Q000628:therapy; D012307:Risk Factors