Schulz Christian M, Burden Amanda, Posner Karen L, Mincer Shawn L, Steadman Randolph, Wagner Klaus J, Domino Karen B
From the Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, München, Germany (C.M.S., K.J.W.); Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, New Jersey (A.B.); Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington (K.L.P., S.L.M., K.B.D.); and Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles Health System, Los Angeles, California (R.S.).
Anesthesiology. 2017 Aug;127(2):326-337. doi: 10.1097/ALN.0000000000001661.
Situational awareness errors may play an important role in the genesis of patient harm. The authors examined closed anesthesia malpractice claims for death or brain damage to determine the frequency and type of situational awareness errors.
Surgical and procedural anesthesia death and brain damage claims in the Anesthesia Closed Claims Project database were analyzed. Situational awareness error was defined as failure to perceive relevant clinical information, failure to comprehend the meaning of available information, or failure to project, anticipate, or plan. Patient and case characteristics, primary damaging events, and anesthesia payments in claims with situational awareness errors were compared to other death and brain damage claims from 2002 to 2013.
Anesthesiologist situational awareness errors contributed to death or brain damage in 198 of 266 claims (74%). Respiratory system damaging events were more common in claims with situational awareness errors (56%) than other claims (21%, P < 0.001). The most common specific respiratory events in error claims were inadequate oxygenation or ventilation (24%), difficult intubation (11%), and aspiration (10%). Payments were made in 85% of situational awareness error claims compared to 46% in other claims (P = 0.001), with no significant difference in payment size. Among 198 claims with anesthesia situational awareness error, perception errors were most common (42%), whereas comprehension errors (29%) and projection errors (29%) were relatively less common.
Situational awareness error definitions were operationalized for reliable application to real-world anesthesia cases. Situational awareness errors may have contributed to catastrophic outcomes in three quarters of recent anesthesia malpractice claims.Situational awareness errors resulting in death or brain damage remain prevalent causes of malpractice claims in the 21st century.
情境意识失误可能在患者伤害的发生中起重要作用。作者检查了因死亡或脑损伤而提出的麻醉医疗事故索赔，以确定情境意识失误的频率和类型。
分析了麻醉封闭索赔项目数据库中的手术和程序性麻醉死亡及脑损伤索赔。情境意识失误被定义为未能察觉相关临床信息、未能理解现有信息的含义或未能进行预测、预期或规划。将存在情境意识失误的索赔中的患者和病例特征、主要损害事件以及麻醉赔付与2002年至2013年的其他死亡和脑损伤索赔进行比较。
在266项索赔中的198项（74%）中，麻醉医生的情境意识失误导致了死亡或脑损伤。与其他索赔（21%，P<0.001）相比，存在情境意识失误的索赔中呼吸系统损害事件更为常见（56%）。失误索赔中最常见的具体呼吸事件是氧合或通气不足（24%）、插管困难（11%）和误吸（10%）。85%的情境意识失误索赔获得了赔付，而其他索赔的赔付比例为46%（P=0.001），赔付金额无显著差异。在198项存在麻醉情境意识失误的索赔中，感知失误最为常见（42%），而理解失误（29%）和预测失误（29%）相对较少见。
情境意识失误的定义得以实施，以便可靠地应用于实际的麻醉病例。情境意识失误可能在近期四分之三的麻醉医疗事故索赔中导致了灾难性后果。导致死亡或脑损伤的情境意识失误在21世纪仍然是医疗事故索赔的常见原因。
