Surgical malpractice cases are increasingly citing obstructive sleep apnea (OSA) as a factor in the patient injury, according to a new study.
In the journal Anesthesia & Analgesia, Dennis Auckley, MD, of the MetroHealth Medical Center in Cleveland, OH, and colleagues reviewed three primary databases of legal literature to find cases in which patients with known or suspected OSA had adverse perioperative outcomes between 1991 and 2010. The article was published online ahead of print.
OSA had to be directly implicated in the outcome, and surgical mishaps such as uncontrolled bleeding were excluded. The adverse perioperative outcome had to result in a lawsuit that then was adjudicated in a court of law with a final decision rendered. There were 77,630 medical negligence cases in the time period studied. The researchers initially excluded 74,576 cases that were unrelated to OSA. Other cases eventually were excluded due to not being directly related to OSA, being non-surgical cases associated with OSA, involving pediatric cases, being settled out of court, or resulting from a surgical complication not related to OSA. The researchers found 24 cases, most occurring in or after 2007, for the final analysis.
Most of the operations (92%) were elective, and 71% of the overall group died. The researchers suspect that use of general anesthesia and opioids might have led to complications in 58% and 38% of cases, respectively. They also found that verdicts favored plaintiffs 58% of the time, with an average award of $2.5 million, ranging from $650,000 to $7.7 million.
Standardized screening tools for OSA should be used more extensively in surgery, the researchers suggest. OSA patients also might need special precautions postoperatively, they say. Some precautions include minimizing opioid use postoperatively, trying to keep patients off their backs, and providing additional monitoring for patients with known or suspected OSA. Patients also should be required to bring their at-home therapy, such as a sleep apnea mask, and use it at the hospital postoperatively, they say.
OSA affects about 5% of the population, but most cases are undiagnosed, the researchers note.
“Perioperative complications related to OSA are increasingly being reported as the central contention of malpractice suits. These cases can be associated with severe financial penalties,” the researchers concluded. “These data likely underestimate the actual medicolegal burden, given that most such cases are settled out of court and are not accounted for in the legal literature.”
An abstract of the study is available online at http://tinyurl.com/q5rxhqc.
The Joint Commission (TJC) has received 61 sentinel event reports in which the patient was diagnosed with or suspected of having OSA. OSA might have been a contributing factor in some of these cases; however, the nature of OSA presents difficulties in directly associating OSA with the patient’s death or injury, the TJC says.
The risk factors for OSA are obesity (BMI > 35), male gender, advancing age, craniofacial or upper airway soft tissue abnormalities, smoking, congestive heart failure, atrial fibrillation, nasal congestion, menopause, and family history, according to The Joint Commission, which quotes a study published in 2015.1
The Joint Commission reviewed root cause information for anesthesia-related events that resulted in death or permanent loss of function from 2004 through June 2015. Most events have multiple root causes. They included:
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anesthesia care, 67 events;
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assessment, 62 events;
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human factors, 61 events;
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communication, 58 events;
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leadership, 51 events;
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physical environment, 17 events;
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information management, 16 events;
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medication use, 16 events;
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continuum of care, 10 events;
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care planning, 10 events.
The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these root cause data are not an epidemiologic data set, and no conclusions should be drawn about the actual relative frequency of root causes or trends in root causes over time, the TJC says.
TJC recommends that hospital and surgical facility staff take the following safety actions:2
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Screen and identify any patient suspected of having OSA.
According to the TJC, some OSA evaluation techniques organizations might want to consider include: Epworth Sleepiness Scale, or ESS (http://bit.ly/1UdFXHF), STOP-BANG Questionnaire (http://www.stopbang.ca/screen.php), Apnea Risk Evaluation System, or ARES (http://bit.ly/1NInPFW), or Berlin questionnaire (http://1.usa.gov/1UdG0mI).
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Evaluate the patient’s plan of care to ensure all precautions are taken while in your facility.
This evaluation includes assessing the use of sedating medications and narcotics, continuous pulse oximetry monitoring of the patient in an observed environment, use of supplemental oxygen or positive airway pressure device, and patient positioning.
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Use guidelines for the use of anesthesia with suspected OSA patients.
TJC reports that you can use the following:3
— For pediatric patients, follow The American Academy of Pediatrics (AAP) revised guidelines for managing and monitoring sedation.
— For adult patients with known OSA, follow the recommendations of the American Society of Anesthesiologists 2006 Task Force.4
“Be aware that intermittent pulse oximetry or continuous bedside oximetry without continuous observation does not provide the same level of safety,” TJC says.
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Strohl KP. Overview of obstructive sleep apnea in adults. UpToDate 2015. Accessed at http://bit.ly/1EWZKUA
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The Joint Commission. At risk: Obstructive sleep apnea patients. Quick Safety 2015. Accessed at http://bit.ly/1SK5tFt.
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Academic Medical Center, Patient Safety Organization. Patient Safety Alert: Obstructive sleep apnea — Management considerations 2013; 19. Accessed at http://bit.ly/1fGQnSj.
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American Society of Anesthesiologists. Practice guidelines for the perioperative management of patients with obstructive sleep apnea. A report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology 2014; 120(2):268-286.
