← All decks
Anaesthesiology
Anesthetic Risk, Quality Improvement, and Liability
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
10 sections · 163 slides
Overview
- Scope of this topic
- Core messages
- Framework of the topic
Anesthesia Risk
- Difficulty of measuring anesthesia risk
- Fall in anesthesia-related mortality
- Sources of variation between mortality estimates
- Estimates of anesthesia-related death across published studies
- Reading the mortality table
- Postoperative peripheral nerve injury
- Lower-extremity neuropathy after lithotomy positioning
- Neurologic injury after regional anesthesia
- Awareness during general anesthesia
- Eye injuries related to anesthesia
- Risk factors for ischemic optic neuropathy after spinal fusion
- Evidence on anemia and hypotension in visual loss
- Dental injury during anesthesia
- Rates of selected anesthesia complications by study
- Rates of dental injury after anesthesia
- Reading the complications table
Risk Management
- Risk management and quality improvement compared
- Overlap between the two programs
- Aspects of risk management relevant to the anesthesiologist
- Key factors in preventing patient injury
- ASA Standards for Basic Anesthetic Monitoring
- Standards higher than the ASA's
- Origin and purpose of clinical checklists
- Expansion of checklists in anesthesia practice
- Evidence for checklists in clinical care
- Staged implementation of the surgical safety checklist
- Purpose of the checklist at each stage
- Using the checklist that follows
- World Health Organization Surgical Safety Checklist elements
- World Health Organization Surgical Safety Checklist elements (continued)
- World Health Organization Surgical Safety Checklist elements (continued)
- Informed consent for anesthesia
- Consent when the plan changes or medication has been given
- Limitations of the informed consent process
- Shared decision making
- Requirements of the anesthesia record
- Consequences of an inadequate record
- Anesthesia information management systems
- Benefits of a well-configured AIMS
- Clinical decision support from AIMS
- Medicolegal concerns raised about electronic records
- Electronic record practices that weaken a defense
- Documenting a critical incident
- Correcting and protecting records after an incident
- Immediate steps after an anesthetic complication
- Communicating with the patient and family
- Benefits of disclosure after an adverse outcome
- Apology laws
- Communication and resolution approaches
- Do-not-resuscitate orders in the perioperative period
- Managing a DNR order before a procedure
- Reinstating a suspended DNR order
- Physician discretion in elective care
National Practitioner Data Bank
- Purpose of the National Practitioner Data Bank
- Reportable actions to the NPDB
- Threshold for reporting a malpractice payment
- Disputing an NPDB report
- Practical effects of NPDB reporting
Quality Improvement and Patient Safety
- Definition of quality in health care
- Six IOM domains of quality
- Foundations of patient safety work
- Structure, process and outcome
- Applying the three-component model
- Limits of the structure-process-outcome model
- Systems view of error in continuous quality improvement
- Inputs to a continuous quality improvement process
- Reframing a quality question in systems terms
- From a controllable cause to a system change
- Reactive and proactive quality improvement
- Methods for proactive process redesign
- Rarity of adverse outcomes as a measurement problem
- Difficulty of measuring desired outcomes
- Critical incidents as intermediate measures
- Value of tracking critical incidents
- Sentinel events
- Investigating a sentinel event
- Human error and system safeguards
- Two categories of human error
- Communication and resolution programs
- Effects of communication and resolution programs
Accreditation and Payment
- Role of the Joint Commission
- Joint Commission quality improvement cycle
- Joint Commission requirements for quality activities
- National Patient Safety Goals
- The preprocedure time-out
- Root cause analysis of sentinel events
- Perioperative sentinel events
- Alternative payment models and pay for performance
- Risk transfer through capitation and bundled payments
- Centers for Medicare and Medicaid Services programs
- Evidence on pay for performance
- Position on future payment models
- National anesthesiology outcomes registries
- Uses of registry data
Professional Liability
- Civil law and the tort system
- Four elements of a successful malpractice suit
- Consequence of failing to prove an element
- Establishing duty
- Establishing breach of duty
- Proximate cause and the standard of proof
- Tests used to establish causation
- Res ipsa loquitur
- Requirements for applying res ipsa loquitur
- Three types of damages
- Punitive damages and other sanctions
- Determining the dollar amount of an award
- Role of expert witnesses
- Information sought about an expert witness
- Outcome bias in judging standard of care
- Findings of the outcome bias study
- Sources that define the standard of care
Causes of Anesthesia-Related Lawsuits
- Proportion of injuries that reach litigation
- Types of anesthesia care in malpractice claims, 2005 to 2014
- Distribution of claims by type of anesthesia care
- Most common injuries leading to anesthesia malpractice claims
- Leading injuries in anesthesia malpractice claims
- Causes of death and permanent brain damage in claims
- Nerve damage and aspiration in closed claims
- Chronic pain management claims
- Human factors identified in recent closed claims studies
What to Do When Sued
- Start of a lawsuit
- Immediate actions on being served
- Preparing the answer to the complaint
- Discovery
- Depositions in a malpractice case
- Conduct during a deposition
- Working with the attorney on expert depositions
- Settlement
- Progression to trial
- Testifying at trial
- Conduct of the defendant during trial
- Meaning of proof in a malpractice case
- Effect of litigation on the anesthesiologist
Summary
- Summary of anesthesia risk
- Summary of risk management and quality improvement
- Summary of liability
- References
- References
- References
- References
- References
- References
- References
- References
- References
- References
- References
- References
- References
- References
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition