Jens Krogh Christoffersen

Analysis of deaths related to anesthesia in the period 1996-2004 from closed claims registered by the Danish Patient Insurance Association.

Background:Anesthesia is associated with complications, and some of them may be fatal. The authors investigated the circumstances under which deaths were associated with anesthesia. In Denmark, the specialty anesthesiology encompasses emergency medicine, chronic and acute pain medicine, anesthetic procedures, perioperative care medicine, and intensive care medicine. Methods:The authors retrospectively investigated anesthesia related deaths registered by the Danish Patient Insurance Association. Results:From 1996 to 2004, 27,971 claims were made by the Danish Patient Insurance Association covering all medical specialties, of which 1,256 files (4.5%) were related to anesthesia. In 24 cases, the patient’s death was considered to result from the anesthetic procedure: 4 deaths were related to airway management, 2 to ventilation management, 4 to central venous catheter placement, 4 as a result of medication errors, 4 from infusion pump problems, and 4 after complications from regional blockades. Severe hemorrhage caused 1 death, and in 1 case the cause was uncertain. Conclusions:Several of the 24 deaths could potentially have been avoided by more extended use of airway algorithm, thorough preoperative evaluation, training, education, and use of protocols for diagnosis and treatment.

Analysis of 136 ureteral injuries in gynecological and obstetrical surgery from completed insurance claims

Objective. Iatrogenic ureteral injury during pelvic surgical procedures is a well‐known complication and important cause of morbidity. The authors investigated the circumstances surrounding registered ureteral injuries in order to identify potential opportunities to prevent such injuries. Design. Evaluation of claims concerning ureteral injuries reported to the Danish Patient Insurance Association. Setting. Danish Patient Insurance Association. Sample. All registered claims for ureteral injuries from 1996 to 2006. Methods. Retrospective study of medical records and data from Danish Patient Insurance Association. Main outcome measures. Preventable ureteral injuries. Results. From 1996 to 2006, 136 submitted claims concerning ureteral injuries were registered. Among these, 73 claims were approved (54%), and compensation paid. In 44 of these, the injury was caused by negligence. Failure to dissect the ureter despite indications for this procedure was the most common type of negligence. Laparotomy procedures were associated with 107 injuries (79%) and 29 injuries (21%) were caused during laparoscopic procedures. Thirty‐four patients suffered from chronic renal dysfunction on the affected side. Only 17 of the ureteral injuries were discovered during the procedure. Conclusions. Forty‐four ureteral injuries could potentially have been avoided using established surgical practices, most importantly by exposing the ureter via dissection when indicated. Most of the ureteral injuries were discovered postoperatively.

Analysis of 127 peripartum hypoxic brain injuries from closed claims registered by the Danish Patient Insurance Association

Background. One of the most feared complications in medicine is hypoxic brain damage to a newborn. The authors investigated the circumstances of registered peripartum hypoxic brain injuries in order to identify potential opportunities to improve patient safety and prevent injuries. Methods. The authors retrospectively investigated peripartum hypoxic brain injuries registered by the Danish Patient Insurance Association. Results. From 1992 to 2004, 127 approved claims concerning peripartum hypoxic brain injuries were registered and subsequently analysed. Thirty‐eight newborns died, and a majority of the 89 surviving children suffered from major handicaps, primarily cerebral palsy. In 69 of the cases, misinterpretation of or late action on an abnormal cardiotocography (CTG) were the reasons for the majority of the hypoxic brain injuries. Conclusions. All injuries could potentially have been avoided using established obstetric practice. CTGs are often misinterpreted. In the authors’ opinion, education and training in CTG interpretation is essential. The use of ST‐analysis of the fetus ECG (STAN) could probably reduce the number of these injuries.

Regional Scintimetry in Scaphoid Fractures

A quantitative scintigraphic method was introduced to examine the proximal, middle and distal third of the carpal scaphoid bone. 99mTc-Sn-pyrophosphate scintimetry was obtained by the use of a gamma camera equipped with a pinhole collimator. Of six patients in whom a unilateral fresh fracture of the scaphoid was clinically suspected, radiology showed a fracture of the scaphoid in four and no fractures in two. The method may be suitable in early diagnosis and further localization of clinically suspected fractures with initially non-diagnostic radiographs.

Severe and fatal obstetric injury claims in relation to labor unit volume

To assess possible association between the incidence of approved claims for severe and fatal obstetric injuries and delivery volume in Denmark.

Closed claims from Switzerland: an important contribution to improving patient safety in anaesthesia.

Studies based on closed claims are very important in our efforts to improve patient safety. For patients, complications of anaesthesia can be compared with ‘friendly fire’. Harm is done unintentionally by somebody whose aim was to help. Patients may be seriously injured or even die due to a complication of anaesthesia, and such events may also lead to serious psychological consequences for the responsible anaesthesiologist.

Reply: The advantages of a centralized compensation system for handling obstetric injury claims

composed of specialized obstetricians. The majority of Korean medical disputes are private, based on individual agreements between the hospital, doctor and patients. At times, a dispute is handled by the Korea Consumer Agency, which addresses consumer disputes rather than medical injuries. As a result of the lack of a centralized reporting system, the Korean government cannot report, calculate or compensate for medical injuries, including medical legal problems in obstetrics. The Korean Society of Obstetrics and Gynecology reported that physicians did not want to be obstetricians and 49% worried about the risk of medical legal problems. Hence, Korean obstetricians do not want to open the labor wards without objective guidelines in a financial compensation system. We believe that the four categories described by the Danish Patient Insurance Association provide simple and subjective guidelines for financial compensation of obstetric injuries, which may be the basis for development of a compensation system in the Republic of Korea. Hae-Hyeog Lee and Tae-Hee Kim* Department of Obstetrics and Gynecology, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea

The size of the labor wards: is bigger better when it comes to patient safety?

To assess possible associations between the size of labor units and the frequency of approved obstetric claims.

Reply: Obstetric injury claims are not happening at random; the size of the labor unit matters

Sir We thank AOGS for the possibility to address some of the issues raised by Nielsen and Clausen. We are convinced that patient claims do not only appear at random, and we judge that our study has shown this. Families involved in preventable major obstetric injuries most likely draw the same conclusion. The perfect parameter to measure obstetric patient safety does not exist. The aim of the study “The size of the labor wards: is bigger better when it comes to patient safety?” (1) was to assess any possible relation between the size of the labor units in Denmark and the frequency of approved claims. Our key finding showed that large labor units (3000–3999 deliveries/year) had a lower approval rate per number of submitted claims compared with small (<1000 deliveries/year), intermediate (1000–2999 deliveries/year), and very large units (≥4000 deliveries/year). No significant difference was identified with regard to the number of submitted claims per number of deliveries between the different sizes of labor units, and on top of this, large labor units are serving a high-risk population to a greater degree, and one could expect a greater potential for injuries happening there. Studies of obstetric patient safety have considered the size of the labor unit before. Moster et al. (2), in their large register-based study from Norway, found that labor units that handle 2000–3000 deliveries per year had a significantly lower number of neonatal deaths after low-risk deliveries, compared with smaller units (2). Similarly, a German study analysed the impact of the labor unit size on neonatal outcome. Smaller units with fewer than 500 deliveries per year were found to have higher birthweight-specific mortality rates compared with larger units (3). Our categorization into four groups with reference to unit size was defined prior to data analysis. The selected group interval was inspired by a report from the Danish Board of Health on labor unit size from 2007 (4). We added an additional group size (≥4000 deliveries/year), as a growing number of deliveries take place in very large units, and we wanted to examine whether there could be a difference between large and very large units. CTG evaluation was not a part of our study, but a comment on this was required in our discussion section, as well as mentioning other potential measures for reducing error. Nielsen and Clausen may have other objectives in writing their Letter to the Editor, as their final commentary on birth clinics and out-of-hospital care has no direct relation to our data. We have explicitly excluded claims concerning injuries arising outside delivery units from our material. Our findings indicated that it might be safest for women to deliver within a large labor unit, but it can be discussed whether it is the size of the labor unit in itself that matters. Several factors may be linked to the size of the labor unit and a large unit may provide a more ideal environment for the implementation of error-reducing initiatives.