ASA Closed Claims: Brain Injury

ASA Closed Claims Program

• The CCP was established in 1984 by the then-president of the ASA to identify major safety vulnerabilities in anesthesiology.¹ The program partners with insurance companies to examine injury and safety-related anesthesia events in closed insurance claims.
• Professional liability coverage for anesthesiologists was, at that time, one of the most expensive for all physicians.  Anesthesiologists comprised only 3% of those covered, but their settlements accounted for 11% of the dollars paid out in claims.¹ The rationale went that by examining undesirable outcomes, anesthesiologists could potentially highlight areas to focus on safety improvement efforts, and over time, this should lead to a lower cost of coverage for insurance companies because fewer claims would be paid out. Both anesthesiologists and insurers could potentially benefit.
• Since 2025, the CCP has been managed by the Anesthesia Quality Institute, a subsidiary of the ASA. It is a database comprised of adverse anesthesia outcomes from closed anesthesia malpractice claim files of insurance companies (16 as of 20172) in the United States.³
• Information is entered into the database without any identifying information, so there is no way to match a database file to a specific claim at an insurance company. It is important to remember that there are important limitations to these data. To start, there is no way to know the true “denominator” when interpreting incidence. For example, in 1999, the CCP had data on 14,500 of 23,000 anesthesiologists but no data on the total number of anesthetics performed by that group. Secondly, not all injured patients file claims. Conversely, some patients with mild or no injury do file claims. All of the data are retrospective and of insufficient quality to establish cause-and-effect relationships. It would be most accurate to describe the CCP as a database of anesthesiology liability, rather than as a measure that directly reflects safety or injury.¹
• However, despite its limitations, the CCP plays a significant role in promoting safety in the field. Anesthesiology-related injuries and safety events are difficult to study because their incidence (even in the 1980s) is quite low. Insurance company files provide a collation of data from across the country and many institutions, making it more likely that a sufficiently large sample can detect injury and safety trends. Retrospective data can be useful for generating hypotheses for future study.¹

Brain Injury

• Some of the most devastating injuries associated with anesthesia care are those that lead to permanent brain injury or death. Of note, patients who sustained brain injuries and subsequently passed as a result of these or other injuries are recorded as deaths under the CCP. Figure 1 shows the proportion of claims that were attributed to death, brain damage, or nerve injury over the decades from 1970 to 1994.¹ This chart is taken from a 1999 study; complete data from the 1990s were not yet available for review at the time of its publication. With focused safety efforts in anesthesiology, the overall severity of these injuries should decrease over time. The data appear to support this hoped-for downward trend in injury severity over time.

• A 2006 study by Cheney et al examined trends in brain injury and death using data from the CCP and found again that the incidence of death and brain damage decreased from 1980-89 to 1990-943, while the total number of claims remained relatively steady. The overall incidence of brain injury decreased from 44% in 1980-89 to 31% in 1990-94.
• Examination of claims showed that the two major mechanisms of injury throughout the study period were respiratory and cardiovascular events. The year 1986 marks an important turning point, as it was when pulse oximetry data and end-tidal carbon dioxide (ETCO2) monitoring began to appear in significant numbers. That trend reflects the beginning of the wide adoption of these monitoring technologies. Use of pulse oximetry and ETCO2 was recommended for all anesthetics in 1986.⁴ Pulse oximetry was officially adopted as the standard of anesthetic care in the 1989 revision of the ASA standards, and ETCO2 monitoring was added to these standards shortly thereafter.⁵
• Improved monitoring is likely not the sole contributor to the downward trend in severe
  complications. Throughout the same time, anesthesiologists have prioritized patient safety as a professional standard. Anesthesiology training quality may have improved. New drugs with improved side effect profiles could have contributed. Given the limitations of the CPP data, it is also possible that there was a shift in the types of cases for which claims were filed. Plaintiff’s attorneys might have focused on suing for less severe injuries, though this possibility seems unlikely given that there was a concomitant decrease in insurance premiums from 1985 to 2005.¹

Errors Associated with Brain Damage and Death

• There are identifiable trends in the CCP data regarding the types of errors most commonly associated with severe injury. Over the period of 1980-86, respiratory events were a leading cause (≥ 50% events) of brain damage and/or death, while cardiovascular etiologies remained relatively stable over the same time (about 27% of events).³ Common respiratory events included difficult intubation, undetected esophageal intubation, inadequate oxygenation and/or ventilation, and premature extubation.¹
• An interesting trend emerged, however, in the period from 1986 to 2000.³ Respiratory events accounted for a decreasing proportion of claims, whereas those attributable to cardiovascular events increased slowly. As of 1992, both types of events appeared to contribute equally.
• There are different explanations for these trends. It is possible that previously attributed events were respiratory complications that were, in fact, cardiovascular in origin. The advent of improved respiratory monitoring in the 1980s enabled more accurate characterization of these events. Alternatively, overall respiratory events may have decreased, while cardiovascular events remained relatively stable.¹
• In 2017, Schultz et al revisited the CCP database with a goal of assessing potential contributions of situational awareness errors to brain injury and death in anesthesia care. This study used a tripartite framework to assess these types of errors. Situational awareness errors were classified as failures to perceive relevant information, to comprehend its implications, or to adequately plan for potential complications. Overall, the first type of error, perception, was the most common, accounting for 42% of situational awareness errors. While this study focused on situational awareness errors, their analysis of CCP data on death or severe brain damage reveals an interesting trend (Figure 2). The downward trend in the incidence of severe injury plateaued in the late 1990s. The drop observed during 2009-2013 reflects an incomplete dataset for this period. Claims may take several years to be filed; some claims remained open at the time of the study, and others were closed but had not yet been fully incorporated into the CCP database. It is likely that the rate of death and brain damage in 2009–2013 will be updated as these additional completed claims are added to the database.

• The investigators for the 2017 study performed an in-depth analysis of CPP data from 2002-2013, and the authors concluded that situational awareness errors likely contributed to over 75% of claims resulting in brain injury or death. From a financial perspective, situational-awareness-type errors were also more likely to result in payment. Insurance payments were made in 85% of claims involving situational awareness errors, compared with 46% of claims not associated with such errors.²
• Most perception errors represented a failure to recognize respiratory insufficiency (60% of errors), though cardiovascular complications accounted for a significant portion as well (20% of errors). In contrast, comprehension errors were equally likely to result from respiratory or cardiovascular complications. Within the subset of cardiovascular complications, a majority of comprehension errors represented a failure to recognize acute hemorrhage. Among projection errors, the most common failures were respiratory in nature. These types of errors included inadequate planning for airway placement management, such as in cases of a difficult airway or a high risk of pulmonary aspiration, as well as insufficient planning for extubation. Projection errors in ambulatory settings frequently involved failures to account for severe patient comorbidities. Another frequently cited projection error relates to recognition of fire risk and failure to take appropriate steps to mitigate fire risk.²