Purpose We analyzed closed civil legal cases in 2007-2016 from the Canadian Medical Protective Association (CMPA) involving specialist anesthesiologists where airway management was the central concern. Methods We included all airway-related civil legal cases involving specialist anesthesiologists that closed from 2007 to 2016. The following variables were abstracted by CMPA medical analysts: clinical context, peer expert opinions of contributing factors, and patient and legal outcomes. Results We found 46 of the 406 (11%) closed cases involving anesthesiologists to be airway-related. Twenty-six cases (57%) involved elective surgery and 31 patients (67%) were categorized as American Society of Anesthesiologists physical status III. Twenty-five cases (54%) occurred outside the operating room (e.g., postanesthesia care unit, intensive care unit, or other satellite locations). In 19 (42%) cases, there was at least one predictor of a difficult airway. Peer experts identified judgement failures in 30 cases (65%), most commonly inadequate airway evaluation. In 30 cases (65%), the patient died or had a permanent brain injury. The medicolegal outcome favoured the patient in 27 (59%) cases, with a median [interquartile range] payment of 422,845 [257,637-935,673] CAD. Conclusions Severe patient harm is common when airway management is the focus of a CMPA medicolegal complaint involving anesthesiologists. Patients were otherwise typically low risk cases presenting for elective surgery. Failure to assess or to change management based on the airway exam or encountered difficulty were the most common errors. Our findings support the continued need for adoption, adherence, and practice of guidelines for anticipated and unanticipated difficult airway management for every patient encounter.
F ET. O 2 ) of ≥ 90% is recommended. Preoxygenation is typically carried out using a tight-fitting facemask with 100% inspired oxygen fraction (FiO 2 ) at a flow rate of 10 L/ min, with 3 to 5 minutes of tidal breathing. As obstetrical intubation often requires prompt induction, alternative preoxygenation methods are being explored.A recent study used high-flow nasal oxygen for preoxygenation for term pregnant women. The study had an up-down sequential allocation design, so the predetermined number of VC breaths used for oxygenation differed for each participant, depending on the previous participant. The number of VC breaths needed to achieve F ET O 2 ≥ 90% was the primary outcome. The study was ended early after collecting data for 20 participants because authors believed the primary outcome could not be achieved in most patients. Successful preoxygenation was achieved in 4 participants receiving HFNO with mouth closed, 3 participants using HFNO with mouth open, and 14 using oxygen facemask.The study only considered the efficacy of achieving F ET O 2 ≥ 90%, but not the efficiency of preoxygenation, meant to prolong the "safe apnea" period, of HFNO. In patients undergoing rapid sequence induction, continued HFNO between the time of neuromuscular blockade to intubation, or "peroxygenation," can improve safety. The efficiency of HFNO has not been studied in pregnant patients due to ethical limitations, but a study by Wong et al, in morbidly obese patients undergoing bariatic surgery found a significant increase in the safe apnea time period in patients who used HFNO compared with standard preoxygenation with a facemask.Multiple studies have found achieving F ET O 2 ≥ 90% in pregnant patients to be challenging. While HFNO may not have a high efficacy, there is evidence from other patient populations that it can provide ongoing apneic oxygenation. Clinicians may need to move forward with the use of HFNO during RSI without reassuring trial data, perhaps by using a tight-fitting facemask combined with HFNO.
This paper describes the recommendations of a national panel on quality improvement in obstetrics to identify priorities for action among five areas of greatest medico-legal risk. Using previously conducted medico-legal data analyses and a systematic literature review, the panel reviewed existing data and developed recommendations for areas of focus in quality improvement in five obstetrical high-risk areas. The panel recommended clarification of definitions in some areas, identified needs for data collection and standardization of practices in others. The most promising interventions to improve care in the five areas were grouped into: standardized processes (such as protocols and communication tools), checklists, audit and feedback, mentoring and coaching, inter-professional communication, simulation and training, and shared decision making guides. This national panel of experts created 18 action-oriented recommendations focused on quality improvement to reduce medico-legal risk and improve the safety of care for Canadian mothers and babies.
This was a successful proof-of-concept study for applying IVRS technology to assess patient safety issues for discharged high-acuity ED patients.
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