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The AANA Foundation Closed Malpractice Claims Study Michael J. Kremer, CRNA, PhD, FAAN Associate Professor & Chair Nurse Anesthesia Department Rosalind Franklin University, North Chicago, IL What is a Closed Claim?

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the aana foundation closed malpractice claims study

The AANA Foundation Closed Malpractice Claims Study

Michael J. Kremer, CRNA, PhD, FAAN

Associate Professor & Chair

Nurse Anesthesia Department

Rosalind Franklin University, North Chicago, IL

what is a closed claim
What is a Closed Claim?
  • A Claim is a demand for financial compensation for an injury that resulted from medical care.
  • A Closed Claim is a claim that has been resolved by an out of court process or litigation.
  • Conduct comprehensive analysis of adverse anesthesia outcomes.
  • Medical malpractice claim files from St. Paul, TIG and CNA Insurance Companies
  • Research team composed of CRNA’s has conducted ongoing review and analysis of over 400 non-dental closed claims files since 1995.
the team
The Team
  • AANA Foundation Liaison
  • Insurance Company Liaison
  • CRNA Educators
  • CRNA Practitioners
  • Statistician
purposes of the study
Purposes of the Study
  • Identify causes of anesthesia patient injury
  • Identify negative patient outcome trends
  • Provide data that can be used to facilitate nurse anesthesia educational curricula
  • Provide data that can be used to facilitate AANA anesthesia practice standard recommendations
primary purpose of the study
Primary Purpose of the Study

Improve Patient Safety

safety initiatives
Safety Initiatives
  • IOM (2003): all health professionals will be educated to deliver patient-centric care as members of an interdisciplinary team, emphasizing evidence-based practice quality improvement approaches and informatics
  • National Quality Forum:
    • 2009 Safe Practices for Better Healthcare
      • 6 years to develop strategies that improve safety of healthcare
    • Recommended evidence-based practices
      • Pediatric imaging, glycemic control, organ donation, catheter-associated UTI, multi-drug resistant organisms

Promoting safe practices. The American Nurse 2009;March/April:4.

evidence based practice
Evidence-Based Practice
  • PICOT questions:
    • Patient population
    • Intervention or area of interest
    • Comparison intervention or comparison group
    • Outcomes
    • Time frame
  • Cochrane Database of Systematic Reviews
benefits of the study
Benefits of the Study
  • Curricular implications
  • Focus for continuing education
  • Advances the body of knowledge regarding anesthesia patient safety
data collection tool
Data Collection Tool
  • Review of literature, examination of other instruments
    • samples of anesthesia records
    • A+ Risk Management Tool
    • AANA Guidelines & Standards for CRNA Practice
  • Face validity established
  • Over 150 datapoints
instrument components
Patient information

Provider information

Anesthesia information

Preexisting conditions

Basis for lawsuit

Disposition of claim

Summary of events

Instrument Components
research process
Research Process
  • Literature review
  • Instrument development
  • Piloted the instrument
  • Revised the instrument
  • Inter-rater reliability #1
  • Refined instrument
  • Inter-rater reliability #2
  • Finalized instructional manual
inter rater reliability
Inter-Rater Reliability
  • Seek to avoid reviewer biases
    • background of the reviewer
    • disposition of the claim/lawsuit
    • nature & extent of injury
    • status of medical records
    • patient outcome
  • Team had 72% inter-rater reliability
research sample
Research Sample
  • Computerized data search
    • all medical liability claims filed between 1995 & 1997
    • filed against CRNA’s named as St. Paul-insured
  • “Long-tail” nature of medical liability
    • 5+ years may elapse from incident  claim closure
inclusion criteria
Inclusion Criteria
  • Claims involving CRNAs
  • Complete anesthesia records
  • Indemnity payment > $1,000
  • Dental claims excluded
data collection
Data Collection
  • Sources:
    • anesthesia records
    • medical records
    • expert reviews
    • narrative statements
    • legal correspondence
    • cost settlement or jury awards
data analysis
Data Analysis
  • Chi Square
  • Mann Whitney
  • Spearman Correlation Coefficient
measurement of care

Measurement of Care

The AANA Standards of Practice

aana standards of practice
AANA Standards of Practice
  • First published in 1992 in the Scope and Standards of Nurse Anesthesia Practice of the Professional Practice Manual for the Certified Registered Nurse Anesthetist, updated in 2007
  • Minimum standard of conduct
  • Applicable to all providers
  • Not prescriptive of methodologies
  • Failure to provide within the standard of care constitutes negligence
  • Violation of one standard can be reflective of the care in general
standard i
Standard I
  • Perform a thorough and complete preanesthesia assessment
  • Patient care responsibility begins with the pre-anesthetic assessment. Except in emergency situations, the CRNA has an obligation to complete a thorough evaluation and determine that relevant tests have been obtained and reviewed.
standard ii
Standard II
  • Obtain informed consent for the planned anesthetic intervention from the patient or legal guardian.
  • The CRNA will obtain or verify that an informed consent has been obtained by a qualified provider. Discuss anesthetic options and risks with the patient and/or legal guardian in language the patient and/or legal guardian can understand. Document in the patient’s medical record that informed consent was obtained.
standard iii
Standard III
  • Formulate a patient-specific plan for anesthesia care.
  • The care plan developed by the CRNA is based upon comprehensive patient assessment, problem analysis, anticipated surgical or therapeutic procedure, patient and surgeon preferences and current anesthesia principles.
standard iv
Standard IV
  • Implement and adjust the anesthesia care plan based on the patient’s physiological response.
  • The CRNA shall induce and maintain anesthesia at required levels, continuously assess the patient’s response to the anesthetic and/or surgical intervention and intervene as required to maintain the patient in a satisfactory physiologic condition.
standard v
Standard V
  • Monitor the patient’s physiologic condition as appropriate for the type of anesthesia and specific patient needs.
    • Monitor ventilation, oxygenation, CV status, temperature, neuromuscular function, positioning continuously
    • Continuous clinical observation and vigilance are the basis of safe anesthesia care.
standard vi
Standard VI
  • There shall be complete, accurate and timely documentation of pertinent information on the patient’s medical record.
  • Document all anesthetic interventions and patient responses. Accurate documentation facilitates comprehensive patient care, provides information for retrospective review and research data, and establishes a medical-legal record.
standard vii
Standard VII
  • Transfer the responsibility for the care of the patient to other qualified providers in a manner which assures continuity of care and patient safety.
  • The CRNA shall assess the patient’s status and determine when it is safe to transfer the responsibility of care to other qualified providers. The CRNA shall accurately report the patient’s condition and all essential information to the provider assuming care for the patient.
standard viii
Standard VIII
  • Adhere to appropriate safety precautions, as established within the institution, to minimize the risks of fire, explosion, electrical shock and equipment malfunction. Document on the patient’s medical record that the anesthesia machine and equipment were checked.
  • Prior to use, the CRNA shall inspect the anesthesia machine and monitors according to established guidelines. The CRNA shall check the readiness, availability, cleanliness & working condition of all equipment to be utilized in the administration of anesthesia care. Ensure disconnect alarm working with mechanical ventilator. Monitor FiO2 with appropriate alarm on
standard ix
Standard IX
  • Precautions shall be taken to minimize the risk of infection to the patient, the CRNA, and other health care providers.
  • Written policies and procedures in infection control shall be developed for personnel and equipment.
standard x
Standard X
  • Anesthesia care shall be assessed to assure its quality and contribution to positive patient outcomes.
  • The CRNA shall participate in the ongoing review and evaluation of the quality and appropriateness of anesthesia care.
standard xi
Standard XI
  • The CRNA shall respect and maintain the basic rights of patients.
  • The CRNA shall support and preserve the rights of patients to personal dignity and ethical norms of practice.
emotional injury crna related n 13
Emotional Injury - CRNA Related n=13
  • CRNA Related
    • Awareness / Recall - 9 (69%)
    • Non-informed consent - 2 (15%)
    • Pain during SAB - 1 (8%)
    • Mac / Pt. Expected Local - 1 (*%)
  • Non-CRNA Related
    • PTSD - high epidural - 1 (100%)
  • Claim could have been prevented by the CRNA: 127/241 (53%)
    • Inadequate pre-induction activities
    • Better technical monitoring
  • Claim could not have been prevented by the CRNA: 46/241 (19%)
  • Cannot be determined: 68/241 (28%)
  • AANA, the Foundation & CNA partnered to review 62 claims involving CRNAs
    • Claims opened between 2003-2007
    • Qualitative and quantitative analysis conducted
  • > 50% of claims
    • Reported death as outcome
    • Most frequent pre-existing conditions were HTN & obesity
    • Were deemed preventable
    • Involved care not consistent with AANA Standards of Care
qualitative analysis
Qualitative Analysis
  • For each claim, mark on spreadsheet standards that were not followed
  • Determine if behavioral issues in the following areas occurred:
    • Ethical inconsistencies
    • Inappropriate anesthesia care
    • Actions of CRNA related to damaging event
    • Lack of vigilance
    • Failure to diagnose condition related to damaging event
    • Failure of skill
    • Lack of knowledge
qualitative analysis67
Qualitative Analysis
  • Written narrative using direct quotes from documents in file, e.g., depositions, legal correspondence, claims manager notes, that demonstrate inconsistencies with the AANA Standards or behavioral areas identified by researchers
  • Provide citations from current literature that provide an evidence-based rationale for the standards and behavioral areas
asa closed claims study
ASA Closed Claims Study
  • The ASA Closed Claims Project is an in-depth investigation of 7328 closed anesthesia malpractice claims designed to identify major areas of loss, patterns of injury, and strategies for prevention.
  •, accessed 4/3/2009
asa closed claims study69
ASA Closed Claims Study

The proportion of claims with permanent & disabling injuries (including death) declined over decades.,

Accessed 4/3/2009

the asa closed claims study
The ASA Closed Claims Study
  • Most common complications in closed claims.
  • Complications are injuries to pts alleged to have resulted from anesthesia care.,

Accessed 4/3/2009

asa closed claims study71
ASA Closed Claims Study
  • Most common damaging events in closed claims.
  • The damaging event is the mechanism that allegedly caused the injury.,

Accessed 4/3/2009

  • Morbidity & mortality are only part of the picture in anesthesia outcome.
    • Patient satisfaction, quality of life questions
  • Closed claims valid & reliable for determining damaging events & adverse outcomes.
  • A multicenter, prospective study would strengthen our understanding of anesthesia outcomes.
where do we go from here
Where do We go from Here?
  • Significantly increase the number of claims analyzed.
  • More comprehensive data analysis.
  • On going evaluation & refinement of instrument(s).
  • Dissemination of research findings.
  • ASA (2008). ASA Closed Claims Project., accessed 7/19/08
  • Beecher, H. & Todd, D. (1954). A study of deaths associated with anesthesia and surgery. Annals of Surgery, 140, 2-25.
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  • Brunner, E. (1984). The national association of insurance commissioners closed claims study. International Anesthesiology Clinics, 22 17-30.
  • Caplan, R., Ward, R., Posner, K. & Cheney, F. (1988). Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology, 68: 5-11.
  • Caplan, R., Vistica, M., Posner, K. & Cheney, F. (1997). Adverse anesthetic outcomes arising from gas delivery equipment: A closed claims analysis. Anesthesiology 87: 741-748.
  • Chadwick, H., Posner, K., Caplan, R., Ward, R. & Cheney, F. (1991). A comparison of obstetric and nonobstetric malpractice claims. Anesthesiology, 74: 242-249.
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  • Fritzlen, T., Kremer, M., Biddle, C. (2003). The AANA Foundation Closed Malpractice Claims Study on nerve injuries during anesthesia care. AANA Journal, 71: 347-352.
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