BANFF, ALTA. — Most obstetric anesthesia malpractice claims for maternal death or brain damage stem from block-related cardiac arrest, primarily caused by inadvertant and unrecognized intrathecal injections, according to an analysis of data from the American Society of Anesthesiologists Closed Claims Project over the last decade.
Careful spinal/epidural placement, both test and incremental dosing, and meticulous management of regional anesthetics would not only reduce this risk but also might reduce claims for more minor injuries, “which are still a very major part of litigation,” said Jo Davies of the department of anesthesiology at the University of Washington Medical Center in Seattle.
The study, which she presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology, analyzed a total of 255 claims associated with obstetric regional anesthesia. “The database contains information on closed anesthesia malpractice claims from 35 insurance companies, which cover about 60% of all anesthesiologists in the United States,” she explained.
Out of the 255 claims, the study focused on those associated with maternal death (21), brain damage (15), emotional distress (26), and pain during delivery/surgery (21). The rest of the claims focused on nerve damage, headache, and backache, she said. “As one might expect, payments were most frequently made for the severe and permanent injuries of maternal death and brain damage—with a much lower rate of payment for minor injuries.”
Overall, in more than 50% of cases, anesthetic management met the standard of care, she said. However, care was found to be substandard in more than 60% of brain damage cases.
Claims for emotional distress and for pain during delivery/surgery sometimes overlapped, with patients suing for both. Inadequate block was the only contributing factor in claims for pain during surgery or delivery, with 95% resulting from cesarean rather than vaginal deliveries, she said. But inadequate block also accounted for 31% of emotional distress claims.
“Although some women vehemently refused conversion to general anesthesia and still sued, what is more disturbing are those cases where conversion to general anesthesia was either delayed or never happened—and one case where there was no verification of adequate analgesia prior to incision,” she said.
Other factors that caused emotional distress were high block causing respiratory distress and conversion to general anesthesia (15%), accidental dural puncture (15%), and unprofessional behavior (8%).
Among emotional distress claims, care was adequate in 75% of cases and payment was made in only 25%.
However, among the claims for pain, care was questionable or inadequate in nearly half because of delayed conversion or failure to convert to general anesthesia, and payment was made in 71% of these claims.
Professional conduct, the provision of realistic expectations, and education regarding the risks associated with obstetric anesthesia “may minimize the number of patients unhappy with their obstetric experience using malpractice litigation as a means of emotional vindication,” noted Ms. Davies.