Equipment Problems as Damaging Events

Journal Articles

1. Caplan RA, Vistica MF, Posner KL, Cheney FW: Adverse Anesthetic Outcomes Arising from Gas Delivery Equipment: A Closed Claims Analysis. Anesthesiology 87: 741-8, 1997. [Abstract, NLM PubMed Link] See also: Anesthesia - General. Order this article from: ASA Closed Claims Project.

   Problems with equipment used in anesthesia gas delivery systems accounted for 72 (2%) of 3,791 claims in the database.  The specific devices involved in these claims were the anesthesia machine, breathing circuit, supplemental oxygen delivery tubing, supply tanks or lines, vaporizors and ventilators.  Misuse of equipment was more common than equipment failure, and most of these equipment problems (76%) resulted in death or brain damage.  Claims associated with gas delivery equipment are infrequent but severe and continue to occur in the 1990's.

2. Domino KB, Bowdle TA, Posner KL, Spitellie PH, Lee LA, Cheney FW. Injuries and Liability Related to Central Vascular Catheters: A Closed Claims Analysis. Anesthesiology. 2004 Jun;100(6):1411-1418. [Abstract, NLM PubMed Link] See also: Cardiovascular System; Monitoring - Physiologic. Order this article from: ASA Closed Claims Project.
   
   Claims for injuries related to central vascular catheters had a greater proportion of death than other claims in the Closed Claims database. The most common central vascular catheter complications causing patient injury were wire/catheter embolus, cardiac tamponade, carotid artery puncture/cannulation, hemothorax, and pneumothorax. Patient safety may be improved by pressure waveform monitoring, use of ultrasound guidance for difficult catheterization, and checking and acting on a chest radiograph after vascular catheter insertion.

Newsletter Articles

1. Bowdle TA: Central line complications from the ASA Closed Claims Project. ASA Newsletter 60(6):22-25, 1996. [Full Text] See also: Cardiovascular System; Monitoring - Physiologic
2. Caplan RA: Liability Arising from Anesthesia Gas Delivery Equipment. ASA Newsletter 62(6):7-9, 1998. [Full Text] See also: Anesthesia - General
3. Bowdle, TA: Central Line Complications From the ASA Closed Claims Project: An Update. ASA Newsletter 66(6): 11-12 & 25, 2002. [Full Text; PDF Version] See also: Cardiovascular System; Monitoring - Physiologic
4. Liau DW : Injuries and Liability Related to Peripheral Catheters: A Closed Claims Analysis. ASA Newsletter 70(6): 11-13 & 16, 2006. [Full Text; PDF Version]

Conference Presentations and ASA Abstracts

1. Spitellie PH, Bowdle TA, Posner KL, Cheney FW, Domino KB: Injuries from Central Lines: A Closed Claims Analysis. Anesthesiology, 96: A1124, 2002. [Full Text] See also: Cardiovascular System; Monitoring - Physiologic
2. Liau DW, Kooner PK, Posner KL, Cheney FW, Domino KB: "Injuries and Liability Related to Peripheral Catheters: A Closed Claims Analysis " Anesthesiology 105: A945, 2006. [Full Abstract Text]