Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Perioperative Research, Brigham and Women's Hospital, Boston, MA.
Pain Physician. 2019 Jul;22(4):389-400.
Closed malpractice claims can provide insight into low-frequency adverse events in many areas of perioperative and chronic pain care. Over the last decade, there have been changes in surgical and regional anesthetic practice, likely impacting adverse event patterns. Given the wide variability and low frequency of complications associated with peripheral nerve blocks, the study of closed malpractice claims offers an opportunity to examine adverse events, and the patient, technical, and provider factors that led to the claim. Knowledge gained from examination of closed claims has already resulted in multiple improvements in processes of care and patient safety.
An investigation of the factors that contributed to medicolegal claims against anesthesia providers related to peripheral nerve blocks.
Retrospective analysis.
Inpatient and outpatient surgery facilities.
The Comparative Benchmarking System database is a medical liability database that contains more than 400,000 malpractice claims from more than 400 academic and community-based institutions accounting for over 30% of malpractice claims in the United States. The present investigation reviewed all (n = 113) available closed malpractice claims related to regional anesthesia (RA) in surgical patients closed between 2006 and 2016, and investigated factors that may have contributed to patient injury, including type of nerve block, type of surgery, nerves injured, resulting neurologic deficits, and potential factors contributing to the injury.
Our data analyzed 62 claims related to RA and showed that most closed claims were classified as permanent minor injuries. The greatest number of claims were for brachial plexus injuries associated with interscalene blocks performed for shoulder or rotator cuff repairs. Femoral and sciatic nerve blocks with resulting lower extremity injuries were the most common nerve blocks resulting in payment. The largest contributing factor to these injuries was noted to be "Technical Knowledge/Performance" of the regionalist followed by "Pre-existing Injury/Radiculopathy." Symptom onset from these claims was most likely to be delayed with the leading initial presenting symptom being paresthesia.
It is difficult to establish cause-effect relationship, and the small sample size limits the ability to detect clinical differences and associations with specific comorbidities or techniques. There was also limited information related to regional anesthetic techniques and medications used that would have helped explore further relationships between the procedure and cause for litigation.
There remains significant room for risk reduction in regional anesthetic practice. Patterns based on the analysis of closed claims show that interscalene blocks are the most common peripheral nerve block resulting in litigation, even when compared with other blocks involving the brachial plexus. Furthermore, patients with existing nerve injury/radiculopathy may also warrant alternative techniques or greater emphasis during informed consent on the increased risk of injury. As most of the presenting symptoms associated with claims are delayed, an opportunity for improvement in postregional care may be better communication with patients following discharge to discuss their postoperative recovery.
Regional, pain, anesthesia, complications, closed claims, liability, nerve, block, injury.
封闭性医疗事故索赔可以深入了解围手术期和慢性疼痛护理领域的低频不良事件。在过去十年中，外科和区域麻醉实践发生了变化，这可能影响了不良事件模式。鉴于周围神经阻滞相关并发症的广泛变异性和低频率，对封闭性医疗事故索赔的研究为检查导致索赔的不良事件以及患者、技术和提供者因素提供了机会。从审查封闭性索赔中获得的知识已经导致了护理过程和患者安全的多项改进。
调查导致与周围神经阻滞相关的麻醉提供者医疗事故索赔的因素。
回顾性分析。
住院和门诊手术设施。
比较基准系统数据库是一个医疗责任数据库，其中包含来自 400 多家学术和社区机构的 40 多万份医疗事故索赔，占美国医疗事故索赔的 30%以上。本研究回顾了 2006 年至 2016 年间与外科患者的区域麻醉（RA）相关的所有（n=113）可用封闭性医疗事故索赔，并调查了可能导致患者受伤的因素，包括神经阻滞类型、手术类型、受伤神经、导致的神经功能缺损以及可能导致受伤的潜在因素。
我们的数据分析了 62 份与 RA 相关的索赔，发现大多数封闭性索赔被归类为永久性轻微损伤。索赔数量最多的是与肩或肩袖修复相关的肩胛上神经丛阻滞引起的臂丛神经损伤。股神经和坐骨神经阻滞导致下肢损伤是最常见的导致付款的神经阻滞。这些损伤的最大促成因素是区域麻醉师的“技术知识/表现”，其次是“先前存在的损伤/神经根病”。这些索赔的症状发作最有可能延迟，最初的主要症状是感觉异常。
很难确定因果关系，并且样本量小限制了检测临床差异和与特定合并症或技术关联的能力。与程序和诉讼原因相关的区域麻醉技术和使用的药物相关信息也很有限，这将有助于进一步探讨两者之间的关系。
区域麻醉实践仍有很大的降低风险的空间。基于封闭性索赔分析的模式表明，即使与涉及臂丛神经的其他阻滞相比，肩胛上神经丛阻滞也是最常见的导致诉讼的周围神经阻滞。此外，患有现有神经损伤/神经根病的患者可能还需要替代技术或在知情同意过程中更加强调增加损伤风险。由于与索赔相关的大多数主要症状是延迟出现的，因此改善区域麻醉后护理的机会可能是在患者出院后更好地与他们沟通，讨论他们的术后恢复情况。
区域、疼痛、麻醉、并发症、封闭性索赔、责任、神经、阻滞、损伤。
