Adverse respiratory events in anesthesia: a closed claims analysis

Adverse outcomes associated with respiratory events constitute the single largest class of injury in the American Society of Anesthesiology Closed Claims Study (522 of 1541 cases; 34%). Death or brain damage occurred in 85% of cases. The median cost of settlement or jury award was +200,000. Most outcomes (72%) were considered preventable with better monitoring. Three mechanisms of injury accounted for three-fourths of the adverse respiratory events: inadequate ventilation (196; 38%), esophageal intubation (94; 18%), and difficult tracheal intubation (87; 17%). Inadequate ventilation was used to describe claims in which it was evident that insufficient gas exchange had produced the adverse outcome, but it was not possible to identify the exact cause. This group was characterized by the highest proportion of cases in which care was considered substandard (90%). The esophageal intubation group was notable for a recurring diagnostic failure: in 48% of cases where auscultation of breath sounds was performed and documented, this test led to the erroneous conclusion that the endotracheal tube was correctly located in the trachea. Claims for difficult tracheal intubation were distinguished by a comparatively small proportion of cases (36%) in which the outcome was considered preventable with better monitoring. A better understanding of respiratory risks may require investigative protocols that initiate data collection immediately upon the recognition of a critical incident or adverse outcome.