Characterization and analysis of adverse events in closed liability cases involving anaesthetists who received legal support from the Colombian Society of Anaesthesia and Resuscitation (S.C.A.R.E.), Colombia, 1993-2012
Introduction: Adverse events are the source of significant care-related morbidity and mortality in surgical patients.
Objective: To characterize and analyze anaesthesia-related adverse events in closed ethical and legal cases, with the involvement of the Colombian Society of Anaesthesia and Resuscitation (Sociedad Colombiana de Anestesiología y Reanimación - S.C.A.R.E.) between 1993 and 2012.
Materials and methods: Retrospective analysis of medical liability cases involving anaesthetists, managed with the support of the Special Fund for Mutual Legal Assistance (FEPASDE).
Results: Overall, 278 proceedings involving anaesthesia-related adverse events were analyzed. The majority (67%) occurred in association with planned surgical procedures (general surgery, orthopaedic surgery, plastic surgery, and obstetrics and gynaecology) performed under general anaesthesia in ASA I patients taken to surgery in Level II complexity settings. A substantial percentage of adverse events (18%) occurred in the Post-Anaesthetic Care Unit (PACU). The most frequent adverse events were cardiovascular and respiratory (55.4% and 36.7% respectively). The most predominant outcomes were death (50.3%) and cerebral insult (22.3%). The analysis found flaws in the completion of the pre-anaesthetic assessment and informed consent forms, compliance with guidelines, standards or protocols, communication with the patient or the family after the event, and communication among the members of the healthcare team.
Conclusions: In the cases reviewed, the majority of adverse events happened in low risk patients, in low complexity institutions. The PACU was a sensitive setting for the occurrence of adverse events. It is important to consider environmental factors when analysing adverse events.
2. Ibarra P, Robledo B, Galindo M, Nino C, Rincón D. Normas mínimas 2009 para el ejercicio de la anestesiología en Colombia. Rev Colomb Anestesiol. 2009;37:235-53.
3. Aranaz-Andres JM, Aibar-Remon C, Limon-Ramírez R, Amarilla A, Restrepo FR, Urroz O, et al. Prevalence of adverse events in the hospitals of five Latin American countries: results of the 'Iberoamerican Study of Adverse Events' (IBEAS). BMJ Quality Safety. 2011;20:1043-51.
4. Aranaz-Andres JM, Aibar-Remon C, Vitaller-Burillo J, Requena-Puche J, Terol-Garcia E, Kelley E, et al. Impact and preventability of adverse events in Spanish public hospitals: results of the Spanish National Stud of Adverse Events (ENEAS). Int J Qual Health Care. 2009;21:408-14.
5. Cheney FW. The American Society of Anesthesiologists Closed Claims Project: what have we learned, how has it affected practice, and how will it affect practice in the future? Anesthesiology. 1999;91:552-6.
6. OMS. Función y responsabilidade de la OMS en las investigaciones sanitarias. Asamblea Mundial de la Salud; 23-05-2007. Ginebra: Organización Mundial de la Salud; 2007.
7. Galindo M. Complicaciones anestésicas. Estudio preliminar. Rev Colomb Anestesiol. 1992;20:273-84.
8. Galindo M. Morbimortalidad por Anestesia en Colombia. Rev Colomb Anestesiol. 2003;31:53-61.
9. OMS. Marco Conceptual de la Clasificación Internacional para la Seguridad del Paciente. Organización Mundial de la Salud; 2009.
10. Taylor-Adams S, Vincent C. System analysis of clinical incidents: the London protocol. Londres: Clinical Safety Research Unit, Imperial College London; 2004. p. 1-17.
11. Aranaz-Andres JM, Aibar-Remon C, Limon-Ramirez R, Amarilla A, Restrepo FR, Urroz O, et al. [IBEAS design: adverse events prevalence in Latin American hospitals]. Rev Calidad Asistencial. 2011;26:194-200.
12. Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, et al. An alternative strategy for studying adverse events in medical care. Lancet. 1997;349:309-13.
13. Petty WC, Kremer M, Biddle C. A synthesis of the Australian Patient Safety Foundation Anesthesia Incident Monitoring Study, the American Society of Anesthesiologists Closed Claims Project, and the American Association of Nurse Anesthetists Closed Claims Study. AANA J. 2002;70:193-202.
14. Metzner J, Posner KL, Lam MS, Domino KB. Closed claims' analysis. Best Pract Res Clin Anaesthesiol. 2011;25:263-76.
15. Kluger MT, Bullock MF. Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia. 2002;57:1060-6.
16. Metzner J, Kent CD. Ambulatory surgery: is the liability risk lower? Curr Opin Aanaesthesiol. 2012;25:654-8.
17. Dutton RP, Lee LA, Stephens LS, Posner KL, Davie JM, Domino KB. Massive hemorrhage: a report from the anesthesia closed claims project. Anesthesiology. 2014;121:450-8.
18. Odom-Forren J. The PACU as critical care unit. J Perianesth Nurs. 2003;18:431-3.
19. Hines R, Barash PG, Watrous G, O'Connor T. Complications occurring in the postanesthesia care unit: a survey. Anesthesia Analgesia. 1992;74:503-9.
20. Kongsayreepong S, Chaibundit C, Chadpaibool J, Komoltri C, Suraseranivongse S, Suwannanonda P, et al. Predictor of core hypothermia and the surgical intensive care unit. Anesthesia Analgesia. 2003;96:826-33.
21. Odom-Forren J. Accurate patient handoffs: imperative for patient safety. J Perianesth Nurs. 2007;22:233-4.
22. Cohen MM, O'Brien-Pallas LL, Copplestone C, Wall R, Porter J, Rose DK. Nursing workload associated with adverse events in the postanesthesia care unit. Anesthesiology. 1999;91:1882-90.
23. Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Griffiths P, Busse R, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014;383:1824-30.
24. Amaya AC, Narváez R, Eslava-Schmalbach J. Trabajo en equipo como factor contribuyente en la ocurrencia de errores médicos o eventos adversos. Rev Colomb Cir. 2013;28:297-310.
25. Halverson AL, Casey JT, Andersson J, Anderson K, Park C, Rademaker AW, et al. Communication failure in the operating room. Surgery. 2011;149:305-10.
26. Smith AF, Pope C, Goodwin D, Mort M. Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room. Br J Anaesth. 2008;101:332-7.
27. Cassinello Plaza F. La importancia del trabajo en equipo en las salas de cirugía. Rev Colomb Anestesiol. 2015;43:1-2.
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