There have been major efforts to improve anesthesia safety since the days memorialized by a television program entitled, "The Deep Sleep -- 6,000 Will Die or Suffer Brain Damage” (see Section III).
Despite those efforts, studies show there is still a steady stream of anesthesia errors which too often cause preventable tragedies like the ones I have seen in my own practice (Section I). The recent death of Joan Rivers is one more example of the problem (see Section IV-VII).
I. Medical errors in anesthesia malpractice cases I have litigated
Overdosage of intravenous pain medication and failure to monitor breathing during cesarean delivery, resulting in maternal brain damage
Failure to protect airway with intubation during general anesthesia for delivery, resulting in maternal death after aspiration pneumonitis
Failure to turn on ventilator after pause for X-ray, failure to monitor breathing and deliberate inactivation of low oxygen alarm during routine gall bladder surgery, resulting in patient’s death
Failure to recognize post-operative respiratory insufficiency and respiratory arrest in Recovery Room, resulting in patient’s death.
All of these cases resulted in a confidential settlement.
II. Some of the expert witnesses I recruited for those cases
James Eckenhoff, M.D.—Former Dean of Northwestern Medical School and co-author of leading textbook of anesthesiology, Introduction to Anesthesia: The Principles of Safe Practice
David Gaba, M.D.—Professor of Anesthesia at Stanford University School of Medicine and expert in human factors engineering in patient safety
Adolph Giesecke, M.D.—Former Chairman of the Department of Anesthesiology, University of Texas Southwestern Medical School
Terry Walman, M.D.—Assistant Professor Department of Anesthesiology and Critical Care Medicine,The Johns Hopkins University School of Medicine.
III. "The Deep Sleep -- 6,000 Will Die or Suffer Brain Damage”
The danger of anesthesia malpractice was first publicized in 1982 when the ABC television
series, “20/20,” aired a program entitled, "The Deep Sleep -- 6,000 Will Die or Suffer Brain Damage.”
The show began with this warning,
"If you are going to go into anesthesia, you are going on a long trip and you should not do it, if you can avoid it in any way.
“General anesthesia is safe most of the time, but there are dangers from human error, carelessness and a critical shortage of anesthesiologists. This year, 6,000 patients will die or suffer brain damage."
After scenes were shown of patients who had suffered anesthesia mishaps, the announcer declared, "The people you have just seen are tragic victims of a danger they never knew existed—mistakes in administering anesthesia.” (1)
Among the problems the show covered were:
accidental drug overdoses,
delayed recognition of allergic reactions,
deaths after oxygen was accidentally turned off, and
anesthesiologists who left anesthetized patients unattended in the operating room while they left to make a phone call, get coffee or see other patients.
"The Deep Sleep -- 6,000 Will Die or Suffer Brain Damage” was a turning point for anesthesiologists in the US.
"It was devastating," said Ellison Pierce Jr., M.D., a former President of the American Society of Anesthesiologists. He was spurred to help found the Anesthesia Patient Safety Foundation, which spearheaded an effort to reform the practice of anesthesiology in the 1990s. (2)
IV. Anesthesia safety in the last 15 years
In 1999, The Institute of Medicine’s report, “To Err is Human: Building a Safer Health Care System,” observed, “Anesthesia is an area in which very impressive improvements in safety have been made.”
Those improvements were attributed to a variety of factors including improved monitoring techniques, the development and adoption of practice guidelines and other systematic approaches to reducing errors.
That impression of improved anesthesia safety was shattered in 2002, when a new study found that the rate of anesthesia-related mortality, as determined by peer review, had not improved over the previous decade.
Robert Lagasse, M.D., the anesthesiologist who conducted the study, declared,
“Based on these findings, the recommendations are quite simple. It is time to tell the emperor that he is not wearing any clothes. We must dispel the myth that anesthesia-related mortality has improved by an order of magnitude. Science does not support this claim.”(3)
Those harsh comments drew this response in an Editorial,
“Is [the] commonly held belief of markedly improved safety imaginary or does [that study’s] analysis miss the mark?
“The truth is somewhere in between… the available data may reflect several points:
anesthesia for healthy patients is “safer” than it once was (but further progress may be possible);
the rate of anesthesia-related mortality for all surgical patients is still higher than desired; and,
safety levels can “plateau” or even diminish over time without constant effort at improvement.”(4)
The Lagasse study was published in 2002. A landmark study published in January, 2016 shows that Dr. Lagasse’s concerns were well-founded.
As discussed in Section VII, the 2016 study found an alarmingly high rate of medication errors by M.D.-anesthesiologists and nurse anesthetists.
Much to its credit, the American Society of Anesthesiologists conducts studies of closed medical malpractice claims as a method for improving patient safety. For example, in 2008, a closed case analysis of claims involving obstetrical anesthesia observed:
“Newborn death/brain damage has decreased, yet it remains a leading cause of obstetric anesthesia malpractice claims over time.
“Potentially preventable anesthetic causes of newborn injury included delays in anesthesia care and poor communication between the obstetrician and anesthesiologist.”(5)
V. Joan Rivers’ death and the danger of anesthesia errors in outpatient facilities
The risk of anesthesia errors in outpatient facilities is of particular concern. In 2009, a closed case analysis of claims involving anesthesia in settings other than a hospital observed,
“A growing number of procedures are performed outside the operating room. In spite of their relatively noninvasive nature, serious adverse outcomes can occur…
“Data from the American Society of Anesthesiologists’ Closed Claims database suggest that anesthesia at remote locations poses a significant risk for the patient, particularly related to oversedation and inadequate oxygenation/ventilation during monitored anesthesia care.
“Similar anesthesia and monitoring standards and guidelines should be used in all anesthesia care areas.”(6)
Joan Rivers death in 2014 illustrates what can happen when an outpatient facility fails to meet basic standards for anesthesia care. She underwent a diagnostic procedure (endoscopy) to investigate complaints of hoarseness and acid reflux.
The procedure required that she be anesthetized so an anesthesiologist gave her propofol (the same anesthetic that was involved in the death of Michael Jackson).
With propofol, there is a fine line between achieving an appropriate level of sedation and producing sedation deep enough that breathing stops altogether.
Medicare investigators later found that Joan Rivers’ doctors failed to notice that her vital signs were deteriorating for at least 15 minutes before she went into the cardiac arrest that led to her death several days later.
Their report concluded,
“The physicians in charge of the care of the patient failed to identify deteriorating vital signs and provide timely intervention during the procedure.”(7)
VI. The conflict between M.D.-anesthesiologists and nurse anesthetists
An M.D.-anesthesiologist delivered the anesthesia care in Joan Rivers case. That disclosure prompted one nurse anesthetist to write,
“Too bad there wasn’t a CRNA [certified registered nurse anesthetist] in the room to ensure Ms. Rivers was safe and alive.”
That comment reflects the ongoing conflict between M.D.-anesthesiologists and nurse anesthetists over whether the nurse anesthetists should be allowed to practice without supervision by M.D.-anesthesiologists.
Today, there are more nurse anesthetists in the US than physician anesthesiologists. This situation has led to a lobbying war over whether requirements for supervision of nurse anesthetists should be abandoned. In 16 states, Medicare already allows nurse anesthetists to practice without supervision by an M.D.-anesthesiologist.(8)
A key issue in that conflict is the difference in education and training. Anesthesiologists must complete a 4-year residency program after four years of medical school. Some go on to fellowship programs for an additional 1-2 years.
Nurse anesthetists, on the other hand, complete nursing school and a 2- or 3-year school of nurse anesthesia.
Jane Fitch, M.D., who became an M.D.-anesthesiologist in 1992 after spending a year and a half as a nurse anesthetist, offered this comparison,
"The biggest difference is that we [M.D. anesthesiologists] see patients preoperatively and can diagnose and treat their medical conditions and get them prepared for anesthesia.
“The majority of problems relate to underlying medical illnesses. You need to know the medical illnesses, as well as the treatments, so that you can make the safest choice of anesthetics, especially in drug-shortage situations where you may be using second- or third-choice drugs.”(9)
VII. Medication errors have been found to occur in almost half of surgeries—what’s needed is “a multi-layered defense”
A landmark study published in January, 2016 reported that anesthesia-related medication errors occurred in almost half of the surgeries that were evaluated.
The mistakes included:
drug documentation mistakes and
failure to properly treat changes in a patient’s vital signs during surgery.(10)
An Editorial declared that “medication errors and adverse event rates may even be higher in other settings such as out-of-hospital or office-based anesthesia care sites and community hospitals.”(11)
Dr. David Katz, director of the Yale University Prevention Research Center observed,
“[A]wareness of problems is where all solutions begin…these numbers are disturbing, but not surprising. Those of us who have worked in hospitals have seen innumerable instances when such errors did occur, or could have…
“[N]o error is acceptable. And yet, as the saying goes, to err is human. So errors will occur if human behavior is the only safeguard against it.
"What all this means is that human behavior cannot be the only safeguard against error. Rather, we need a multi-layered defense, involving careful humans backing one another up, and automatic systems backing up the humans.”(12)
The most important lesson I have learned from litigating anesthesia cases is that it’s important to investigate not only what happened in the operating room but also what happened before the incident to prevent anesthesia errors from harming patients.
If you find that an anesthesia error occurred in the absence of appropriate safety measures, the hospital or outpatient facility should be held accountable along with the M.D.-anesthesiologist or nurse anesthetist who committed the error.
1. Pierce EC. Looking Back: Doctor Pierce Reflects. APSF Newsletter, Spring 2007.
2. Boodman S. Diagnosing Medical Errors: In the Wake of Widely Publicized Mistakes, Doctors Try To Make Hospitals Safer. Washington Post. November 19, 1996.
3. Lagasse RS. Anesthesia Safety: Model or Myth? A Review of the Published Literature and Analysis of Current Original Data. Anesthesiology; 2002; 97:1609–17.
4. Cooper JB; Gaba D. No Myth: Anesthesia Is a Model for Addressing Patient Safety. Anesthesiology 2002; 97:1335-1337.
5. Davies JM et al. Liability Associated with Obstetric Anesthesia—A Closed Claims Analysis. Anesthesiology 2009; 110:131–9.
6. Metzner J et al. The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anaesthesiol. 2009; 22:502-8.
7. Hartocollis A. Joan Rivers’s Treatment Had Numerous Violations, US Inquiry Finds. New York Times, Nov. 10, 2014.
8. Siebert KS. Why can’t physician anesthesiologists, nurse anesthetists, and anesthesiologist assistants just get along? MedPage Today. March 10, 2015.
9. Hayes JC. Anesthesiologist-CRNA Teamwork Common But Groups At Odds. Medscape Anesthesiology. April 10, 2012.
10. Nanji KC et al. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology 2016; 124:25-34.
11. Orser BA. Perioperative Medication Errors: Building Safer Systems. Anesthesiology 2016; 124:1-3.
12. Mozes A. Medication errors common during surgery, study finds. CBS News Health Day,October 26, 2015.