I recently came across an interesting article in the American Association of Nurse Anesthesiology (AANA) Journal that explored at preventable acts of medical malpractice involving certified registered nurse anesthetists (CRNAs).
What are nurse anesthetists?
Some people may be unfamiliar with the field of nurse anesthesiology or certified registered nurse anesthetists (CRNAs). CRNAs are registered nurses with additional graduate-level training in the nursing administration and management of anesthesia, including general anesthesia during surgery.
As the job title suggests, nurse anesthetists are not physician anesthesiologists.
The scope of practice of CRNAs differs by state, but the trend is moving toward fewer restrictions. In some states, nurse anesthetists are able to practice fully within their field without being overseen by a physician.
In Texas, nurse anesthetists must be linked to a physician anesthesiologist. In Texas and other states that require CRNA oversight, there are basically two models that may be used for CRNAs to practice in the anesthesia field:
• Medical direction allows one anesthesiologist physician to be responsible for up to four patients with four different CRNAs providing anesthesia care at once.
• Medical supervision allows one anesthesiologist physician to be responsible for five or more patients with four different CRNAs providing anesthesia care at once.
Preventable medical malpractice involving CRNAs
The AANA identified three categories of common preventable claims involving nurse anesthetists. Let’s address each of them.
Communication failures
The AANA Journal noted the communication failures between nurse anesthetists and patients, anesthesiologists, and surgeons or other healthcare providers have been commonly linked to medical errors.
The closed claims study cited an example of miscommunication when a physician anesthesiologist completed the preanesthetic evaluation, but key findings weren’t discussed with the CRNA who would be handling the operating room anesthesia care.
The preanesthetic evaluation is a critical aspect of anesthesia care for any patient about to go to surgery. It requires the anesthesiologist physician or nurse anesthetist to interview the patient and perform a focused physical exam to determine if it’s safe for the patient to receive anesthesia and undergo surgery.
Among other things, anesthesiologists and CRNAs should look for airway issues, cardiac problems, or other factors that may need to be addressed before proceeding. After completing the preanesthetic evaluation, the anesthesiologist or CRNA formulates an anesthetic plan.
Based on my experience in handling anesthesia claims, I’m not surprised that problems are common in this area. The AANA study noted one case where a physician anesthesiologist handled the pre-anesthetic evaluation, but didn’t document or communicate to the CRNA that the patient had pulmonary hypertension managed with home oxygen. When the CRNA started general anesthesia, the patient went into severe bradycardia (slow heart rate) and developed a brain injury.
The lesson here is that when there’s a team approach to anesthesia care, everyone on the team needs to be aware of the preanesthetic evaluation findings. Preferably, the anesthesiologist and CRNA should both be present for the preanesthetic exam. Both always need to be in the know about key findings, though.
Failure to comply with standards
The AANA study found that 75% of preventable claims against nurse anesthetists involved a violation of the American Association of Nurse Anesthesiology Standards.
There are 14 standards in the publication, but two of them stand out to me.
• Standard 2: Preanesthesia Patient Assessment and Evaluation. This standard recommends that nurse anesthetists perform and document the preanesthetic exam.
As mentioned in the example above, in many hospitals and states, it’s the anesthesiologist physician who performs the preanesthetic exam before turning over the operating room care to a CRNA. If a CRNA is providing the operating room care, it’s important for the CRNA to be involved in the preanesthetic assessment, or, at a minimum, to be familiar with the findings.
• Standard 3: Plan for Anesthesia Care. The same is true for the anesthetic plan. This AANA standard states, “After the patient has had the opportunity to consider anesthesia care options and address his or her concerns, formulate a patient-specific plan for anesthesia care.”
This is an important point that shouldn’t be overlooked. Part of the informed consent process is to discuss anesthesia care options. This not only includes the type of anesthesia to be administered, but also the education, training, and experience of the anesthesia provider.
Some patients may only want care by a physician anesthesiologist, and that’s their right. Other patients may prefer a certified registered nurse anesthetist, and that’s their right. Based on my experience, this important information often isn’t communicated to patients, who are just shuffled to the next stage in the process without a real opportunity to make an informed decision.
Errors in judgment
The AANA study noted that another common preventable error in CRNA medical malpractice claims involves cognitive errors. The study identified the top 10 cognitive errors in anesthesia practice as anchoring, availability bias, premature closure, feedback bias, framing effect, confirmation bias, omission bias, commission bias, overconfidence, and sunk costs.
Providing anesthesia care often requires complex decision making that occurs rapidly. This presents a high potential for decision-making errors. The AANA study noted that anesthesia care involves situational awareness, which requires perceiving elements in the current situation and understanding how they impact managing care. Past experience with similar situations, training, and skills/abilities will affect the individual’s comprehension of the situation.
In other words, the AANA study concluded that when it comes to preventing errors in anesthesia care, education, training, and experience matters. The study noted that, “it is likely that a considerable number of adverse events during anesthesia care are caused by a loss of situational awareness.”
If you’ve been seriously injured because of poor anesthesia care in Texas, then contact a top-rated experienced Texas medical malpractice lawyer for a free consultation about your potential case.
