ADVERSE ANESTHETIC OUTCOMES ARISING FROM GAS DELIVERY EQUIPMENT - A CLOSED CLAIMS ANALYSIS

Background Anesthesia gas delivery equipment is a potentially importan t source of patient injury. To better define the contribution of gas d elivery equipment to professional liability in anesthesia, the authors conducted an in-depth analysis of cases from the database of the Amer ican Society of Anesthesiologists Closed Claims Project. Methods: The database of the Closed Claims Project is composed of closed US malprac tice claims that have been collected in a standardized manner. All cla ims resulting from the use of gas delivery equipment were reviewed for recurrent patterns of injury. Results: Gas delivery equipment was ass ociated with 72 (2%) of 3,791 claims in the database. Death and perman ent brain damage accounted for almost all adverse outcomes (n = 55, 76 %). Equipment misuse was defined as fault or human error associated wi th the preparation, maintenance, or deployment of a medical device. Eq uipment failure was defined as unexpected malfunction of a medical dev ice, despite routine maintenance and previous uneventful use. Misuse o f equipment (n = 54, 75%) was three times more common than equipment f ailure (n = 17, 24%). Misconnects and disconnects of the breathing cir cuit made the largest contribution to injury (n = 25, 35%). Reviewers judged that 38 of 72 claims (53%) could have been prevented by pulse o ximetry, capnography, or a combination of these two monitors. Overall, 56 of 72 gas delivery claims (78%) were deemed preventable with the u se or better use of monitors. The year of occurrence for claims involv ing gas delivery equipment ranged from 1962 to 1991 and did not differ significantly from claims involving other adverse respiratory events. Conclusions: Claims associated with gas delivery equipment are infreq uent but severe and continue to occur in the 1990s. Educational and pr eventive strategies that focus on equipment misuse and breathing circu it configuration may have the greatest potential for enhancing the saf ety of anesthesia gas delivery equipment.