Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea.
Department of Medical Law and Ethics, Graduate School, Yonsei University, Seoul, Korea.
Korean J Anesthesiol. 2021 Dec;74(6):506-513. doi: 10.4097/kja.21020. Epub 2021 Mar 25.
Medical malpractice during endotracheal intubation can result in catastrophic complications. However, there are no reports on these severe complications in South Korea. We aimed to investigate the severe complications associated with endotracheal intubation occurring in South Korea, via medicolegal analysis.
We retrospectively analyzed the closed judicial precedents regarding complications related to endotracheal intubation lodged between January 1994 and June 2020, using the database of the Supreme Court of Korea. We collected clinical and judicial characteristics from the judgments and analyzed the medical malpractices related to endotracheal intubation.
Of 220 potential cases, 63 were included in the final analysis. The most common event location was the operating room (n = 20, 31.7%). All but 3 cases were associated with significant permanent or more severe injury, including 31 deaths. The most common problems were failed or delayed intubation (n = 56, 88.9%). Supraglottic airway device was used in 5.2% (n = 3) cases of delayed or failed intubation. Fifty-one (81%) cases were ruled in favor of the plaintiff in the claims for damages, with a median payment of Korean Won 133,897,845 (38,000,000, 308,538,274). The most common malpractice recognized by the court was that of not attempting an alternative airway technique (n = 32, 50.8%), followed by violation of the duty of explanation (n = 10, 15.9%).
Our results could increase physicians' awareness of the major complications related to endotracheal intubation and help ensure patient safety.
气管插管过程中的医疗事故可能导致灾难性的并发症。然而，韩国尚无关于这些严重并发症的报告。我们旨在通过法医学分析，调查韩国发生的与气管插管相关的严重并发症。
我们通过韩国最高法院的数据库，回顾性分析了 1994 年 1 月至 2020 年 6 月期间提交的与气管插管相关并发症的封闭司法先例。我们从判决中收集了临床和司法特征，并分析了与气管插管相关的医疗事故。
在 220 个潜在病例中，有 63 个被纳入最终分析。最常见的事件发生地点是手术室（n = 20，31.7%）。除 3 例外，所有病例均与显著的永久性或更严重的损伤有关，包括 31 例死亡。最常见的问题是插管失败或延迟（n = 56，88.9%）。在插管失败或延迟的病例中，有 5.2%（n = 3）使用了声门上气道装置。在损害赔偿请求中，有 51 例（81%）案件对原告有利，赔偿中位数为韩元 133,897,845 元（38,000,000 韩元，308,538,274 韩元）。法院认定的最常见医疗事故是未尝试替代气道技术（n = 32，50.8%），其次是违反解释义务（n = 10，15.9%）。
我们的研究结果可以提高医生对与气管插管相关的主要并发症的认识，有助于确保患者安全。
