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Analysis of Anesthesia-related Medical Disputes in the 2009-2014 Period Using the Korean Society of Anesthesiologists Database

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Author(s)
Woon-Seok RohDuk-Kyung KimYoung-Hun JeonSeong-Hyop KimSeung-Cheol LeeYoung-Kwon KoYong-Cheol LeeGyu-Hong Lee
Keimyung Author(s)
Lee, Yong Cheol
Department
Dept. of Anesthesiology & Pain Medicine (마취통증의학)
Journal Title
Journal of Korean Medical Science
Issued Date
2015
Volume
30
Issue
2
Keyword
Adverse EffectsInjuriesLegislationMalpractice
Abstract
Using the Korean Society of Anesthesiologists database of anesthesia-related medical
disputes (July 2009-June 2014), causative mechanisms and injury patterns were analyzed.
In total, 105 cases were analyzed. Most patients were aged < 60 yr (82.9%) and were
classified as American Society of Anesthesiologists physical status ≤ II (90.5%). In 42.9%
of all cases, the injuries were determined to be ‘avoidable’ if the appropriate standard of
care had been applied. Sedation was the sec most common type of anesthesia (37.1% of
all cases), following by general anesthesia. Most sedation cases (27/39, 69.2%) showed a
common lack of vigilance: no pre-procedural testing (82.1%), absence of anesthesia
record (89.7%), and non-use of intra-procedural monitoring (15.4%). Most sedation
(92.3%) was provided simultaneously by the non-anesthesiologists who performed the
procedures. After the resulting injuries were grouped into four categories (temporary,
permanent/minor, permanent/major, and death), their causative mechanisms were
analyzed in cases with permanent injuries (n = 20) and death (n = 82). A ‘respiratory
events’ was the leading causative mechanism (56/102, 54.9%). Of these, the most
common specific mechanism was hypoxia secondary to airway obstruction or respiratory
depression (n = 31). The sec most common damaging event was a ‘cardiovascular events’
(26/102, 25.5%), in which myocardial infarction was the most common specific
mechanism (n = 12). Our database analysis demonstrated several typical injury profiles (a
lack of vigilance in seemingly safe procedures or sedation, non-compliance with the airway
management guidelines, and the prevalence of myocardial infarction) and can be helpful
to improve patient safety.
Keimyung Author(s)(Kor)
이용철
Publisher
School of Medicine
Citation
Woon-Seok Roh et al. (2015). Analysis of Anesthesia-related Medical Disputes in the 2009-2014 Period Using the Korean Society of Anesthesiologists Database. Journal of Korean Medical Science, 30(2), 207–213. doi: 10.3346/jkms.2015.30.2.207
Type
Article
ISSN
1011-8934
DOI
10.3346/jkms.2015.30.2.207
URI
https://kumel.medlib.dsmc.or.kr/handle/2015.oak/34086
Appears in Collections:
1. School of Medicine (의과대학) > Dept. of Anesthesiology & Pain Medicine (마취통증의학)
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