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June 1999
Volume 63 |
Number 6
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| The Closed Claims
Project: Looking Back, Looking Forward |
Robert A. Caplan, M.D.,
Chair
ASA Committee on Professional Liability
The end of a calendar year traditionally leads to reflections
about the recent past and resolutions for the forthcoming months.
The approaching millennium provides a similar opportunity, but
from a broader perspective. For the Committee on Professional
Liability, 1999 marks the 15th year of the ASA
Closed Claims Project. That is a long enough history to warrant
an overview of progress and some predictions about the challenges
lying ahead.
Looking Back
The usefulness of closed claims data was first appreciated in
the early 1980s at the University of Washington by Richard J.
Ward, M.D., Professor of Anesthesiology, and Richard J. Solazzi,
M.D., then a resident in anesthesiology. While studying closed
malpractice claims against anesthesiologists in Washington State,
Drs. Ward and Solazzi realized that these cases provided an enriched
environment for collecting information about rare but often catastrophic
events. They also realized that the opportunity to collect a large
set of rare events might reveal recurring themes and insights
that would be difficult to discern by the practitioners who experienced
these cases as isolated events.
In 1984, Dr. Ward convinced Ellison C. Pierce, Jr., M.D., who
was then ASA President, that a nationwide project would be the
best way to realize the potential benefits of closed claims analysis.
Dr. Pierce agreed and the Closed Claims Project was established
in 1985 under the direction of Frederick W. Cheney, M.D., Chair
of the ASA Committee on Professional Liability. Since then, the
Closed Claims Project has been the one of the main activities
of the Committee.
The goal of the Closed Claims Project is to discover unappreciated
patterns of anesthesia care that may contribute to patient injury
and subsequent litigation. This goal is rooted in the basic philosophy
that prevention of adverse outcomes is the best method
for controlling the costs of professional liability.
The initial years of the Closed Claims Project were challenging.
The Committee had to develop a standardized survey form for data
collection and then train reviewers to use this form. In conjunction
with data collection, the Committee also had to establish a computer-based
system for coding, storing and analyzing data. Insurance companies
were initially reluctant to have their closed claims reviewed
by outside physicians. After a slow start in the mid-1980s, the
project gained wide acceptance throughout the insurance industry
and the number of participating companies steadily increased.
Today, closed claims are obtained from 35 insurance carriers.
In aggregate, these companies insure approximately 50 percent
of practicing physicians in the United States. More than 60 members
of ASA make a voluntary contribution of time to serve as reviewers
for the Closed Claims Project. The Society owes a great deal of
gratitude to these reviewers, who have devoted many long hours
to claims review, often at sites distant from home. The current
database contains approximately 4,000 claims that span a three-decade
interval from 1970 through mid-1990. (The database does not contain
the most recent claims because the process of claim investigation
and resolution typically creates a lag time of about three to
five years.) The Closed Claims database represents the world's
single largest resource for the in-depth study of major adverse
outcomes related to anesthesia care.
The Closed Claims Project has played an important role in understanding
anesthesia liability and promoting patient safety. For example,
by the late 1980s, analysis of the database led to the clear recognition
that respiratory-related events were the single most important
source of anesthesia liability and that most of these events were
preventable. These findings compelled ASA to develop standards
and guidelines relating to pulse oximetry, capnography and management
of the difficult airway. The Project also affords an opportunity
to discern previously unrecognized sources of risk and to suggest
strategies for further study and prevention. This was first demonstrated
in 1988 with an extensive study of sudden cardiac arrest during
spinal anesthesia. Other in-depth studies have yielded important
insights about diverse problems such as burns from warming devices,
peripheral nerve injury, intraoperative awareness, injuries arising
from gas delivery equipment and the effects of bias and variation
on expert review. Overall, the findings of the Closed Claims Project
have been published in 19 journal articles. A list of publications
and a synopsis of each study can be found at the Web site of the
Closed Claims Project, <http://depts.washington.edu/asaccp/
ASA/index.html>.
Looking Ahead
The recent stream of cases entering the Closed Claims database
suggests that the landscape of anesthesia liability is changing.
Happily, the direction of change is favorable for the most severe
injuries. Death and brain damage accounted for 56 percent of all
database claims in the 1970s, compared to 45 percent of all claims
in the 1980s and 31 percent of all claims in the 1990s. Of note,
the contribution of respiratory events to death and brain damage
is diminishing. In the decade of the 1970s, adverse respiratory
events accounted for 55 percent of all claims for death or brain
damage, compared to 50 percent in the 1980s and 45 percent in
the 1990s. The three most common adverse respiratory events associated
with death or brain damage are inadequate ventilation, esophageal
intubation and difficult intubation. Among these three events,
the most dramatic change has occurred in the category of inadequate
ventilation, which accounted for 22 percent of all claims for
death or brain damage in the 1970s, but only 7 percent of these
claims in the 1990s. A similar but smaller change has occurred
with esophageal intubation, which accounted for 10 percent of
all claims for death or brain damage in the 1970s, compared to
7 percent in the 1990s. What accounts for these favorable trends?
The widespread use of pulse oximetry and capnography may be playing
an important role, as suggested by the observation that more than
two-thirds of adverse respiratory events in the database are considered
preventable with the use or better use of one or both of these
monitors.
If claims for death and brain damage continue to decline, peripheral
nerve injury may eventually emerge as the leading source of claims
against anesthesiologists. Currently, peripheral nerve injury
is the second most common class of injury, accounting for 16 percent
of claims in the database. (By comparison, death is the most common
injury, accounting for 32 percent of all claims.) An in-depth
analysis of claims for peripheral nerve injury has recently been
published (see Anesthesiology 1999; 90:1062-1069). This
new study adds support to a growing body of evidence that most
injuries to the ulnar nerve and brachial plexus occur under conditions
of conventional positioning and padding. The study also supports
the observation that conventional explanations for perioperative
nerve injury (for example, compression or stretch) are rarely
evident. Taken together, these findings indicate that we do not
yet have a clear or useful understanding of the basic mechanisms
of perioperative nerve injury, and that this lack of knowledge
impedes our ability to both establish cause-and-effect relationships
and develop effective preventive strategies. Another interesting
feature of this analysis is that injuries to the spinal cord are
increasing. The two most common factors associated with claims
for spinal cord injury are the administration of blocks for chronic
pain management and the administration of blocks in the presence
of systemic heparinization. An accompanying
NEWSLETTER article by Donna Kalauokalani, M.D., provides
further observations about liability patterns emerging in the
area of pain management.
The resources of the Closed Claims Project are now developed
well enough to be exported for use in related areas of inquiry.
An important example of this capability is the Pediatric Perioperative
Cardiac Arrest (POCA) Registry. This registry, initiated in 1994
under the direction of Jeffrey P. Morray, M.D., and Jeremy M.
Geiduscheck, M.D., represents a joint effort by the ASA Closed
Claims Project and the Quality Assurance Committee of the American
Academy of Pediatrics Section on Anesthesiology. The impetus for
creating the registry arose after an in-depth study of pediatric
cases in the Closed Claims database showed that a specific mechanism
for cardiac arrest could not be determined in a large number of
pediatric cases. The goal of the POCA Registry is to explore the
causes of cardiac arrest in children using the data collection
methods and investigative techniques developed by the Closed Claims
Project. Thus far, 63 institutions have submitted nearly 300 cases
of cardiac arrest that have occurred over four years and the administration
of approximately 1 million pediatric anesthetics. Analysis of
this initial information is under way, and will hopefully lead
to a better understanding of perioperative cardiac arrest in pediatric
patients.
What direction will the Closed Claims Project take in coming years?
The primary objective will be to strengthen the Project's role as
a national quality assurance system for the specialty of anesthesiology.
This role has evolved for at least two reasons. First, the database
is large enough to discern sources of injury that are poorly understood
or previously unrecognized. The recognition of such injuries provides
an important stimulus for focusing attention on areas of basic research
that may lead to improvements in patient safety. Second, the use
of standardized data collection and analysis tools creates an opportunity
to detect and measure changing patterns of liability over time.
By studying these changing patterns, we can learn how preventive
strategies are either succeeding or failing and thereby make more
effective decisions about allocating resources for improving patient
safety. In this regard, the ability to detect new sources of injury
is particularly important and efforts are now under way to obtain
a more timely understanding of emerging areas of risk.
Robert A. Caplan, M.D., is Clinical Professor
of Anesthesiology, University of Washington, and Staff Anesthesiologist,
Virginia Mason Medical Center, Seattle, Washington.
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