Morray J P, Geiduschek J M, Caplan R A, Posner K L, Gild W M, Cheney F W
University of Washington School of Medicine, Seattle.
Anesthesiology. 1993 Mar;78(3):461-7. doi: 10.1097/00000542-199303000-00009.
Since 1985, the Committee on Professional Liability of the American Society of Anesthesiologists has evaluated closed anesthesia malpractice claims. This study compared pediatric and adult closed claims with respect to the mechanisms of injury, outcome, the costs, and the role of care judged to be substandard.
Using a standardized form and method developed for analysis of closed claims, the American Society of Anesthesiologists Closed Claims Data Base was used to compare pediatric with adult anesthesia-related adverse events.
Of the 2,400 total claims, 238 (10%) were in the pediatric age group (15 yr of age or younger). The pediatric claims presented a different distribution of damaging events compared with that of adults. In particular, respiratory events were more common among pediatric claims (43% versus 30% in adult claims; P < or = 0.01). The mortality rate was greater in the pediatric claims (50% versus 35% in adult claims; P < or = 0.01), anesthetic care more often was judged less than appropriate (54% versus 44% in adult claims; P < or = 0.01), the complications more frequently were thought to be preventable with better monitoring (45% versus 30% in adult claims; P < or = 0.01), and the distribution of payments to the plaintiff was different (median payment, $111,234 versus $90,000 in adult claims; P < or = 0.05). Many of the differences between pediatric and adult claims were explained by a higher prevalence of patient injury caused by inadequate ventilation in the pediatric claims (20% versus 9% in adult claims; P < or = 0.01). In pediatric compared with adult inadequate ventilation claims, poor medical condition and/or obesity (6% versus 41%; P < or = 0.01) were uncommon associated factors. Cyanosis (49%) and/or bradycardia (64%) often preceded cardiac arrest in pediatric claims related to inadequate ventilation, resulting in death (70%) or brain damage (30%) in previously healthy children. Although clinical clues suggested hypoxemia as a common mechanism of injury, the files did not contain enough information to explain the genesis of hypoxemia in these claims.
Comparison of adult and pediatric closed claims revealed a large prevalence of respiratory related damaging events--most frequently related to inadequate ventilation. In the opinion of the reviewers, 89% of the pediatric claims related to inadequate ventilation could have been prevented with pulse oximetry and/or end tidal CO2 measurement. However, pulse oximetry appeared to prevent poor outcome in only one of seven claims in which pulse oximetry was used and could possibly have done so.
自1985年以来，美国麻醉医师协会职业责任委员会一直在评估已结案的麻醉医疗事故索赔。本研究比较了儿科和成人已结案索赔在损伤机制、结果、成本以及被判定为不合格护理的作用方面的情况。
使用为分析已结案索赔而开发的标准化表格和方法，美国麻醉医师协会已结案索赔数据库被用于比较儿科与成人麻醉相关不良事件。
在总共2400起索赔中，238起（10%）发生在儿科年龄组（15岁及以下）。与成人索赔相比，儿科索赔中损伤事件的分布有所不同。特别是，呼吸事件在儿科索赔中更为常见（43%，而成人索赔中为30%；P≤0.01）。儿科索赔中的死亡率更高（50%，而成人索赔中为35%；P≤0.01），麻醉护理更常被判定为不适当（54%，而成人索赔中为44%；P≤0.01），并发症更常被认为通过更好的监测是可以预防的（45%，而成人索赔中为30%；P≤0.01），并且支付给原告的款项分布也不同（中位数支付额，儿科索赔为111,234美元，而成人索赔为90,000美元；P≤0.05）。儿科和成人索赔之间的许多差异可以通过儿科索赔中因通气不足导致患者损伤的发生率较高来解释（20%，而成人索赔中为9%；P≤0.01）。与成人通气不足索赔相比，儿科通气不足索赔中病情不佳和/或肥胖（6%对41%；P≤0.01）是不常见的相关因素。在与通气不足相关的儿科索赔中，心脏骤停之前常有发绀（49%）和/或心动过缓（64%），导致原本健康的儿童死亡（70%）或脑损伤（30%）。尽管临床线索表明低氧血症是常见的损伤机制，但档案中没有足够信息来解释这些索赔中低氧血症的发生原因。
成人和儿科已结案索赔的比较显示，与呼吸相关的损伤事件发生率很高——最常见的是与通气不足有关。评审人员认为，89%与通气不足相关的儿科索赔通过脉搏血氧饱和度测定和/或呼气末二氧化碳测量本可预防。然而，在使用了脉搏血氧饱和度测定且有可能预防不良结局唯一的7起索赔中，脉搏血氧饱和度测定似乎仅预防了1起索赔的不良结局。
