Analysis of Anesthesia-related Medical Disputes in the 2009-2014 Period Using the Korean Society of Anesthesiologists Database.
10.3346/jkms.2015.30.2.207
- Author:
Woon Seok ROH
1
;
Duk Kyung KIM
;
Young Hun JEON
;
Seong Hyop KIM
;
Seung Cheol LEE
;
Young Kwon KO
;
Yong Cheol LEE
;
Gyu Hong LEE
Author Information
1. Department of Anesthesiology and Pain Medicine, School of Medicine, The Catholic University of Daegu, Daegu, Korea.
- Publication Type:Original Article
- Keywords:
Adverse Effects;
Injuries;
Legislation;
Malpractice
- MeSH:
Adult;
Anesthesia, General/*adverse effects;
Anoxia/epidemiology;
Female;
Humans;
Male;
*Malpractice;
*Medical Errors;
Middle Aged;
Myocardial Infarction/epidemiology;
Republic of Korea/epidemiology
- From:Journal of Korean Medical Science
2015;30(2):207-213
- CountryRepublic of Korea
- Language:English
-
Abstract:
Using the Korean Society of Anesthesiologists database of anesthesia-related medical disputes (July 2009-June 2014), causative mechanisms and injury patterns were analyzed. In total, 105 cases were analyzed. Most patients were aged < 60 yr (82.9%) and were classified as American Society of Anesthesiologists physical status < or = II (90.5%). In 42.9% of all cases, the injuries were determined to be 'avoidable' if the appropriate standard of care had been applied. Sedation was the sec most common type of anesthesia (37.1% of all cases), following by general anesthesia. Most sedation cases (27/39, 69.2%) showed a common lack of vigilance: no pre-procedural testing (82.1%), absence of anesthesia record (89.7%), and non-use of intra-procedural monitoring (15.4%). Most sedation (92.3%) was provided simultaneously by the non-anesthesiologists who performed the procedures. After the resulting injuries were grouped into four categories (temporary, permanent/minor, permanent/major, and death), their causative mechanisms were analyzed in cases with permanent injuries (n=20) and death (n=82). A 'respiratory events' was the leading causative mechanism (56/102, 54.9%). Of these, the most common specific mechanism was hypoxia secondary to airway obstruction or respiratory depression (n=31). The sec most common damaging event was a 'cardiovascular events' (26/102, 25.5%), in which myocardial infarction was the most common specific mechanism (n=12). Our database analysis demonstrated several typical injury profiles (a lack of vigilance in seemingly safe procedures or sedation, non-compliance with the airway management guidelines, and the prevalence of myocardial infarction) and can be helpful to improve patient safety.
