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Preoperative Assessments Key Factor in Anesthesia Malpractice Claims

Analysis  |  By Christopher Cheney  
   December 20, 2019

The lead author of a new report identifies four ways to promote preoperative assessments by anesthesiologists.

The lead author of a new report that found weak preoperative assessments are a primary cause of anesthesiology malpractice claims says anesthesiologists and surgical teams can rise to the challenge.

The report was published by The Doctors Company, a large physician-owned medical malpractice insurer headquartered in Napa, California. Based on review of malpractice claims from 2013 to 2018, improper management of patients under anesthesia was the most common anesthesia allegation, at 32%. Deficiencies in patient assessments were among the top three factors identified in claims, along with patient monitoring and communication among providers.

Productivity pressure plays a key role in limiting preoperative assessments and selecting the safest care setting, the report says.

"A review of cases revealed limited opportunities to conduct pre-op assessments. Older and sicker patients needed closer investigation, but production pressures often limited testing and input from attending or referral physicians. These pressures also limited anesthesia professionals' opportunities to arrange for the safest location for anesthesia care (hospital operating room versus a remote ambulatory surgery center or GI or cardiac labs) or to prepare for complications," the report says.

Promoting preoperative assessments

There are four primary ways to help ensure that thorough preoperative assessments are conducted, the lead author of the report told HealthLeaders this week.

1. Collaborative care teams: "The old 'surgeon is captain of the ship' is not now a viable model for modern preoperative planning," said Susan Palmer, MD, a board-certified practicing anesthesiologist based in Eugene, Oregon.

Collaboration among members of the surgical care team is good for healthcare providers and patients, she said. "What we now know is best for patients is that all physicians and nurses involved in a patient's care should work as a team, and knowledgeable input from anyone on the team should be considered respectfully. Collaborative practice is recognized as important not just for job satisfaction of healthcare providers, but also to provide the safest possible patient care."

2. Taking finances into account: The financial impact of delaying a procedure on the day of surgery cannot be ignore, Palmer said.

Healthcare providers including the surgeon, the anesthesiologist, and the care facility take a financial hit when surgery is postponed for factors that could have been identified in a preoperative assessment, she said, adding that patients can also incur personal and familial costs when a surgery is postponed. "This is why it is critical that anesthesiologists can be able to access the information they need ahead of time to properly plan the anesthesia care and make recommendations about the location for the surgery," Palmer said.

3. Obtaining records: At least a week before surgery is scheduled, patients should provide consent to obtain records from relevant healthcare providers and anesthesiologists should have access to those records, she said.

"Anesthesiology department leaders must work with their hospital administrators to make sure a pathway to obtaining and assembling preoperative medical records before surgery exists and is appropriately supported by medical records and nursing personnel. Anesthesiologists can review those records and order any indicated tests or obtain any necessary consultations. When this kind of system is in place, the cancellation on day of surgery rate goes way down."

4. Working with patients: Also at least a week before surgery, patients should be able to request a consultation with the procedure's anesthesiologist, Palmer said. "This is optimal if either the patient has concerns, questions, or requests about anesthesia care, or if the patient has chronic medical problems that should be optimized before the stresses of anesthesia and surgery."

Pre-anesthesia evaluation

There are several main elements of preoperative assessments by anesthesiologists, Palmer said.

  • Medical history
  • Review of current medications and allergies
  • History and description of any personal or family problems with anesthesia
  • Evaluation of chronic medical conditions such as hypertension, diabetes, pulmonary disease, renal disease, cardiac disease, neuromuscular disease, and central nervous system problems
  • Anything that limits a patient's ability to respond to stress should be quantitatively evaluated
  • Physical examination of the patient's airway anatomy
  • Evaluation of cardiac rhythms

"The medical evaluation will aid in the planning of anesthetic techniques, the choice of anesthetic medicines, and the planning for post-operative care," Palmer said.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


In a review of anesthesia malpractice claims at The Doctors Company, improper management of patients under anesthesia was the most common anesthesia allegation.

The review found deficient preoperative assessments were a primary factor in claims alleging improper management of patients.

Strategies to promote preoperative assessments include fostering collaborative care teams and obtaining a patient's medical records at least a week before a surgical procedure.

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