Medical malpractice statistics are sobering. One in three providers will be sued over the course of their career (StatPearls. 2024). The annual overall rate of paid malpractice claims among all specialties is 14.1 per 1,000 physician-years (JAMA Intern Med 2017;177:710-8). Anesthesiologists experience an annual rate of paid malpractice claims of 11.7 per 1,000 physician-years, with 10% of paid malpractice claims reaching over $1 million.
Avoidable errors are common: they may account for up to 251,000 deaths per year, or 9.5% of all deaths in the United States (BMJ Qual Saf 2024;33:109-20). Although the overall number of malpractice claims may have been flat for the past several years, defense costs and large verdicts have risen dramatically, resulting in hundreds of millions of dollars in malpractice costs and higher malpractice insurance rates. Around 97% of successful claims may be settled out of court, but that does not eliminate the professional and emotional consequences for anesthesiologists, even when sued while delivering good quality care (asamonitor.pub/3YbU62Z). In more extreme circumstances, physicians abandon the practice of medicine because of the high visibility of malpractice claims, emotional fear of litigation, or mental anguish from past malpractice suits (J Healthc Qual Res 2018;33:284-9).
Anesthesiology has become safer over time. Safety systems developed by anesthesiologists and colleagues have reduced the incidence of severe injuries and deaths in the perioperative period. An ASA Closed Claims database analysis demonstrates a reduction in cases of brain damage and death related to anesthesiology, mostly attributed to better patient monitoring and adherence to best practice guidelines such as the ASA Difficult Airway Algorithm. However, there are other areas where the results are not as positive. There are increasing anesthesiology claims for monitored anesthesia care (MAC), nonoperating room anesthesia (NORA), and office-based surgery procedures. Cases related to acute and chronic pain management are rising as well. In the postoperative period, there is an increase in the rate of failure-to-rescue patients who are experiencing anesthesia complications. Despite attention and awareness, tooth injuries are still the most common claim, and airway fires remain a persistent problem (Anesthesiology 2006;105:1081-6).
What can good anesthesiologists do to reduce exposure to these growing risks for medical malpractice claims? It is well recognized that NORA and MAC procedures may be some of the “sickest” patients encountered in anesthesia practice. It's critical to accept that although general anesthesia may be avoided in these patients, the consequences and outcomes of these anesthetics may still be significant and dangerous. Often, patients, families, and proceduralists do not recognize the risks involved in NORA and MAC anesthetics. Therefore, it is incumbent upon the anesthesiologist to thoroughly evaluate, assess, and examine these patients as well as discuss the risks with all the stakeholders, some of whom may not acknowledge that a minor outpatient procedure can still have deleterious results.
It is also increasingly understood that the adverse outcomes in the setting of NORA and MAC cases are frequently related to respiratory events. Therefore, it is important to screen for pulmonary problems and employ the highest level of respiratory monitoring and vigilance for these patients. Further, anesthesiologists should be careful to pay attention to the postoperative patient course. Even though anesthesia care has ended, the anesthesiologist remains responsible for patients in the postoperative setting and must have systems and practices in place to monitor for and detect complications before rescue maneuvers are required. Lastly, thorough examination and documentation of preexisting dental disease will go a long way toward reducing the incidence and severity of dental claims for airway damage. With these safety tips in mind, it is hoped that anesthesiologists can reduce the incidence and severity of malpractice claims in the future.
Takeaway tips for reducing malpractice liability exposure include:
Understanding the risks of NORA and MAC anesthetics and educating stakeholders
Recognizing and reducing the incidence of respiratory events in NORA and MAC anesthetics
Monitoring and deterring complications in the postoperative setting before rescue is required
Thoroughly examining and documenting dental disease prior to anesthesia.
ASA Patient Safety Editorial Board contributors: Jonathan B. Cohen, MD, Alexander F. Arriaga, MD, MPH, Jeffrey A. Green, MD, MSHA, FASA, ScD, Keith J. Ruskin, MD, Senthilkumar Sadhasivam, MD, MPH, MBA, FASA, Deborah Schwengel, MD, MEHP (Editor-in-Chief), Scott C. Watkins, MD.
