Closed Claims—Open Insights: Preoperative Anesthesia Planning

Background

A 59-year-old male patient with a history of diabetes, hypertension, myocardial infarction, coronary artery bypass graft, congestive heart failure, non-ischemic cardiomyopathy, and an automatic implanted cardiac defibrillator was scheduled for an upper endoscopy due to nausea and abdominal pain. The gastroenterologist did not obtain preoperative consultation from a cardiologist or the patient’s primary care provider. On the day of the procedure, the anesthesiologist noted that preoperative consultation had not been obtained. After questioning the patient and assessing his condition, the anesthesiologist determined that he was an appropriate candidate for outpatient anesthesia. The patient was sedated, and the procedure was completed. Following the procedure, the patient exhibited a dangerously low heart rate and abnormally low blood pressure. He was intubated and resuscitated, then transferred to the hospital, where he was diagnosed with cardiogenic shock. The patient ultimately expired less than a month after the procedure.

Allegations

• Improper treatment, delay in diagnosing respiratory distress, and delay in transfer to the hospital led to the patient’s death.
• This death caused the claimant’s loss of companionship, comfort, society, guidance, and protection by the deceased.

Case Review Insights

• There was no preoperative clearance from a cardiologist.
• The pre-anesthesia notes misstated that the patient was female with only mild systemic heart disease.
• The informed consent form was incomplete.
• The post-op record, prepopulated by the anesthesiologist, erroneously indicated that there was a “satisfactory recovery with no anesthesia complications.”
• Documentation of post-operative care was limited.
• There was conflicting testimony as to the sequence and timing of events.
• The anesthesiologist also misled the surgical center by falsely indicating he was board-certified in anesthesiology.

Lessons Learned

• Set clear patient‑selection guidelines for ambulatory procedures.
• Review all documentation for accuracy and completeness.
• Develop written emergency protocols.
• Review current certifications as part of the credentialing process.

Risk Management Tips

• Patients with conditions that increase anesthesia risk should be referred to a facility equipped to manage them safely.
• Complete and document all pre‑anesthesia requirements. This includes the pre‑anesthesia exam, informed consent, and delaying any final disposition notes until the patient is officially discharged or transferred.
• Create a written patient‑transfer protocol for safely and quickly moving patients to a designated alternate facility when emergency or extended care is needed.
• Require training for all staff on pre‑ and post‑operative processes, documentation, and emergency procedures, and apply disciplinary action when standards are not followed.

Risk Management Resources

Curi Resources

If you have questions about this topic, please call 800-328-5532 to speak with one of Curi’s Risk Solutions Consultants, or consult the following:

• Risk Management Guide: Management of Medical Emergencies
• Risk Management Guide: Documentation
• Informed Consent Toolkit

External Resources

• American Society of Anesthesiologists. Practice Parameters: Basic Standards for Pre-anesthesia Care. https://www.asahq.org/standards-and-practice-parameters/basic-standards-for-preanesthesia-care

Disclaimer

Curi’s risk mitigation resources and guidance are offered for educational and informational purposes only. This information is not medical or legal advice, does not replace independent professional judgment, does not constitute an endorsement of any kind, should not be deemed authoritative, and does not establish a standard of care in clinical settings or in courts of law. If you need legal advice, you should consult your independent/corporate counsel. We have found that using risk mitigation efforts can reduce malpractice risk; however, we do not make any guarantees that following these risk recommendations will prevent a complaint, claim, or suit from occurring, or mitigate the outcome(s) associated with any of them.