MENELIK II HEALTH SCIENCE COLLEGE DEPARTMENT OF

ANESTHESIA

RESEARCH ON PERIOPERATIVE MALPRACTICE OF ANESTHETIST

(THE CASE OF RAS DESTA MEMORIAL GENERAL HOSPITAL IN
ADDIS ABEBA ETHIOPIA)

A SENIOR RESEARCH PAPER TO BE SUBMITTED TO MINILIKI II HEALTH SCIENCE

COLLEGE IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE DEGREE OF
BACHELOR OF SCIENCE IN ANESTHESIA.

PREPARED BY: ALAYU DEJENIE

TADESE LETA

ADVISOR: Mr. Dereje M.

April 2018
Acknowledgement
First and for most our deepest gratitude goes to our Almighty God for giving us the opportunity
to being student of anesthesia and the strength to finish this study successfully. Second, we
would like to express our deepest gratitude to our advisor Dereje Mamo for his dedicated
interest, support and unreserved guidance throughout this work.

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List of Acronyms
GA……General anesthesia
RA……. Regional anesthesia.
MAC… monitored anesthesia care.
LMA……. Laryngeal mask airway.
ASA…………American Society of Anesthesiology.
CRNA………Certified Registered Nurse Anesthetist.
NPO…………nothing by mouth.

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Table of Contents
Chapter 1 ......................................................................................................................................... 5
1. Introduction ................................................................................................................................. 5
1.1 Background information ........................................................................................................... 5
1.2 Statement of the Problem .......................................................................................................... 7
1.3 Significance of the study........................................................................................................... 8
Chapter 2 Literature review .......................................................................................................... 10
2.1 INTRODUCTION .................................................................................................................. 10
2.2. Responsibilities of the anesthetist toward his patients ....................................................... 14
2.3. COUSE OF PERIOPERATIVE MALPRACTICE ........................................................... 16
Chapter 3 OBJECTIVES .............................................................................................................. 17
3.1 General Objectives .................................................................................................................. 17
3.2 Specific objectives .................................................................................................................. 17
Chapter 4 Methods and Materials ................................................................................................. 18
4.1 study Area and Study population ............................................................................................ 18
4.2 Sample size and sampling Techniques ................................................................................... 18
4.4 Method of Data collection ...................................................................................................... 19
4.3 Method of Data Presentation, Analysis, and Interpretations .................................................. 19
4.5 Data quality assurance ............................................................................................................ 20
4.6 Ethical Consideration .............................................................................................................. 20
4.7 Dissemination of results.......................................................................................................... 20
CHAPTER FIVE DATA PRESENTATION ANALYSIS AND INTERPRETATION .............. 21
5.1. Data presentation analysis and interpretations ................................................................... 21
Chapter Six Conclusion and Recommendations ........................................................................... 29
6.1. CONCLUSION .................................................................................................................. 29
6.2. RECOMMENDATIONS ................................................................................................... 30
REFFERENCE ............................................................................................................................. 31
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Abstract

In this paper the Perioperative malpractice of anesthetist in Ethiopia was investigated in Ras
Desta General Memorial Hospital in Addis Ababa

Data were obtained via questionnaire and personal observation. The questioner designed for the
anesthetist and for student of anesthesia. 9 questioners were distributed to and collected from the
anesthetist and from 18 questioners distributed to The total number of anesthetists in the hospital
is 12 but we only get 9 respondents. The questionnaire was distributed to 9 anesthetists and all
were returned.

The findings of the study indicated that there is perioperative malpractice of anesthetist like
Inadequate pre-op assessment and preparedness, lack of intra-op vigilance, not checking the
anesthesia machine and equipment based on master plan, and inappropriate use of intraoperative
monitoring or not using the five standard monitoring. Almost all respondents indicate that they
use only pulsoxymetry and blood pressure apparatus to monitor the patient and also use weight
estimations to calculate dose of anesthetics. Respondents also indicated that their institution has
shortage of equipment that used to manage difficult airway.

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Chapter 1

1. Introduction

1.1 Background information

The specialty of anesthesia began in the mid nineteenth century and became firmly established
less than six decades ago. Oliver Wendell Holmes in 1846 was the first to propose use of the
term to denote the state that incorporates amnesia, analgesia, and narcosis to make painless
surgery possible. In the United States, use of the term anesthesiology to denote the practice or
study of anesthesia was first proposed in the second decade of the twentieth century to
emphasize the growing scientific basis of the specialty. (1)

Nowadays, Anesthetists are involved in running the intensive care unit and are an integral part of
the resuscitation team in most hospitals. Although anesthesia now rests on scientific foundations
comparable to those of other specialties, the practice of anesthesia remains very much a mixture
of science and art. Moreover, the practice has expanded well beyond rendering patients
insensible to pain during surgery or obstetric delivery the specialty uniquely requires a working
familiarity with a long list of other specialties, including surgery and its subspecialties, internal
medicine, pediatrics, and obstetrics as well as clinical pharmacology, applied physiology, and
biomedical technology. (1)

As the complementary fields of surgery and anesthesiology matured together, new skills were
required of the anesthesiologist, including expertise in resuscitation, fluid replacement, airway
management, oxygen transport, operative stress reduction, and postoperative pain control.
Today, personnel from the anesthesiology department are located throughout the hospital,
ranging from the ambulatory care center to the intensive care unit. (3)

Malpractice, as defined by Black's Law, is "the bad, wrong, or injurious treatment of a patient
professionally, resulting in injury, unnecessary suffering, or death to the patient, and proceeding
from ignorance, carelessness, want of professional skill, disregard for established rules or
principles, neglect, or a malicious criminal intent." Malpractice may be criminal ("violation of a
5

penal law in the management of a case by a physician who thereby subjects himself to
prosecution by the State"); or it may be civil ("wherein a physician had inflicted injury or death
upon a patient by his treatment, but not in violation of any statute of criminal law")(12)

A primary responsibility of the anesthesia provider is to administer a safe anesthetic that also
produces an acceptable patient outcome. Safe anesthetic care has been said to include the
following discrete functions. Collection of sufficient data for preoperative and perioperative
planning, Administration of a physiologically sound anesthetic, reflective of the patient's
condition and type of anticipated surgery, Collection of appropriate perioperative data to
evaluate the patient's course and extrapolation of pertinent information which allows timely and
efficacious interventions, if required, competent evaluation of all instituted therapies,
documentation of all events surrounding the perioperative course in the medical record,
Institution of all decision making and clinical judgment within the framework of accepted
clinical and academic theory, as well as accepted standards of patient care.(2)

The anesthetist can now be held fully responsible for his own actions; he can no longer claim
then security once afforded by the hospital or the surgeon. He regards himself as having the
particular qualifications of special knowledge and skill. He regards himself as having the
particular qualifications of special knowledge and skill. "He must treat with an ordinary and
reasonable degree of skill, exercise care and diligence, and use his best judgment at all times. His
duty to 'take care' implies not to be negligent."(2)

Legally, it is possible to be negligent without being careless, and to make an error in judgment in
administering an anesthetic without being negligent. The anesthetist, however, is negligent, if
with too little training he carries out a dangerous and unnecessary procedure, even
though with great care, if it results in the death of the patient.

Recent research indicates that human error or lack of attention are major contributors to adverse
patient outcomes during anesthesia administration. Yet few studies exist which have addressed
Anesthetist and anesthesiologist patient outcomes and differences in legal actions filed against
these two types of providers.
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 1.2 Statement of the Problem

Though the role of anesthesiologist is crucial, different 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. (4).

It has been said that "any patient with less than a perfect end result is a potential malpractice-suit
investigator, and no physician, regardless of his excellence, or the purity or benevolence of his
motives, is immune from malpractice actions. “Professional liability has practically become a
definite occupational hazard of medicine. A survey made by the American Medical Association
showed that in only one of every seven malpractice actions is negligence shown on the part of
the physician, except those in which the jury infers negligence commonly referred to as the 'rule
of sympathy'.

Using the Korean Society of Anesthesiologists database of anesthesia-related medical disputes

(July 2009-June 2014), In 42.9% of all cases, the injuries were determined to be ‘avoidable’ if
the appropriate standard of care had been applied (10). Analysis of cases according to anesthetic
technique revealed that, with the exception of 4 cases, both general anesthesia and sedation cases
resulted in grave complications (i.e., permanent/major injuries or death) (10).

Regardless of whether the defendant is acquitted or convicted, anesthesia has been classified as a
high risk specialty (2). This classification was based on the fact that the state of hypnosis may
result in airway obstruction, pulmonary aspiration or trauma2. Also, the anesthetic drugs may
have undesirable adverse effects on both the cardiovascular and respiratory systems. The
anesthetized patient is totally dependent on the anesthetist and equipment’s for maintenance of
patient’s vital activities (2).

Different articles and meta-analysis studies worldwide tackling the scope of anesthesia-related
malpractice, confirm the fact that cardiorespiratory arrest and cerebral damage resulting from
hypoxemia were the leading causes of mortality or drastic morbidity. Oxygen supply to the
7
patient is of the highest concern, defect in alveolar gas exchange or oxygen delivery to the
tissues, equipment failure or compromised upper airway with the inability to adequately ventilate
a hypnotized, sedated and/or paralyzed patient, is of paramount concern.

Medication-related MAC claims included administration of the wrong drug or dose and adverse
drug reactions also the most common Couse of injuries. Examples of medication-related injuries
included unexpected neuromuscular blockade while awake after mistaken administration of
vecuronium; anaphylaxis after administration of ketorolac to a patient with an aspirin allergy;
infection after contaminated propofol; and agitation, vomiting, or excessive sedation after
opioids or sedative agents (12).

1.3 Significance of the study

The main aim of giving important details about cases is to widen the scope of anesthetists for
matters that may be considered out of their responsibility and who may believe that their main
role is only intraoperative management. This should not lead to “defensive medicine” attitude but
rather to implement a safe practice of medicine for the patient which is our ultimate interest (3).

Such type of studies is of immense importance to all stakeholders participated during planning
the program and to those parties mentioned as beneficiaries of the program. Accordingly,
different stake holders and upcoming researchers can make use of the outcome of this research.

This research paper was eventually help in identifying the areas of weakness and based on the
findings, strategies to assess perioperative malpractice of Anesthetist with anesthesia considered
as important component of quality assurance program for both private and public health
institution.

Studies was conducted to assess perioperative malpractice of anesthetist regarding anesthesia

service Because Recent research indicates that human error or lack of attention are major
contributors to adverse patient outcomes during anesthesia administration.
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Because of human error is routinely blamed for disasters in the air, on the railways, in complex
surgery, and in health care generally. However, quick judgments and routine assignment of
blame obscure a more complex truth. The identification of an obvious departure from good
practice is usually only the first step of an investigation. Although a particular action or omission
may be the immediate cause of an incident, closer analysis usually reveals a series of events and
departures from safe practice, each influenced by the working environment and the wider
organizational context.

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Chapter 2 Literature review

2.1 INTRODUCTION
Different articles and meta-analysis studies worldwide tackling the scope of anesthesia-related
malpractice, confirm the fact that cardiorespiratory arrest and cerebral damage resulting from
hypoxemia were the leading causes of mortality or drastic morbidity (2) Oxygen supply to the
patient is of the highest concern, defect in alveolar gas exchange or oxygen delivery to the
tissues, equipment failure or compromised upper airway with the inability to adequately ventilate
a hypnotized, sedated and/or paralyzed patient (2), is of paramount concern.

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. (10)

Sedation was the second 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. From all cases that have been referred during
the 5-yr study period. Most patients were under the age of 60 yr (87/105, 82.9%) and were
classified as ASA physical status I or II (95/105, 90.5%). Although cases related to general
anesthesia were the most common, sedation cases were similarly prevalent, accounting for
37.1% of all cases.

Airway management comprises a significant aspect of professional liability to the

anesthesiologist. The ASA Closed Claims Project database demonstrates that difficult intubation
is the second most frequent primary damaging event leading to anesthesia malpractice claims. It
is responsible for 6.4 percent of 4,459 claims in the closed claims database. Not only does
10

difficult intubation lead to a significant proportion of claims, the severity of outcome can be
devastating. Brain damage or death was the outcome in 57 percent of the 283 claims involving
difficult intubation, compared to an incidence of 43 percent in all other claims. Despite the
severity of outcome, there is essentially no difference in the total payment amount resulting from
claims involving difficult intubation as opposed to all other claims. (13)

The sec largest subclass of respiratory events was difficult tracheal intubation (14.3% of all
respiratory events). Of these, there were two cases of an anticipated difficult airway (cervical
fracture and ankylosing spondylitis with morbid obesity), in which the first strategy was
persistent attempts at laryngoscopic intubation without any preparation for a difficult airway.
None of the difficult intubation cases reflected the use of a supraglottic airway such as a
laryngeal mask airway for providing rescue ventilation in difficult airway management. In five
cases, an emergency tracheostomy was finally attempted, but was unsuccessful, thereby resulting
in death. In cases of difficult airway, repeated attempts at laryngoscopic intubation can lead to a
'cannot intubate and cannot ventilate' situation, as well as airway and hemodynamic
complications. (10)

Thus, familiarity with difficult airway practice guideline and the skills required to anticipate and
manage a difficult airway are essential for every clinician who performs anesthesia or sedation.
One closed claims study found that after publication of the guidelines, difficult airway claims
associated with death or brain damage during induction decreased from 62% to 35%. (10)

Inability to mask-ventilate occurred in 37 percent of the 98 difficult airway claims. Patient

consent and/or cooperation was troublesome in 7 percent of cases. Once the management of the
airway was established as challenging, what types of strategies were employed? Repeated
nonsurgical intubation attempts took place in most cases. None of these nonsurgical attempts
included the laryngeal mask airway (LMA), as most closed claims predate the widespread use of
this device in anesthesia practice. There is, however, no information available regarding whether
regional anesthesia, local anesthesia or monitored anesthesia care (MAC) was a viable
alternative or appropriate management in any more than 2 percent of cases.

In the situation in which the anesthesia care provider predicted a difficult airway, 28 percent of
11

the claims (10 of 36) contained no explicit information about a reformulated strategy for
management of the airway. Of the claims that reported a specific plan, various options for airway
management were considered prior to the start of anesthesia. In two-thirds of cases, an awake
nonsurgical intubation was planned, 25 percent planned an awake surgical airway (tracheostomy)
and 25 percent planned an induction with the ablation of spontaneous ventilation followed by
intubation.

As the above percentages suggest, the providers may have prepared for several alternatives of
airway management. The most common management strategy was persistent nonsurgical
attempts. Of note, closed claims reviewers considered most of these repeated attempts to be
inappropriately persistent. Again, it should be noted that the LMA was not a common option
when these claims occurred.

An emergency situation (defined as "cannot intubate and cannot ventilate") was reported to occur
in nearly half of all 98 claims in which difficult airway management data were available. In the
36 cases with an anticipated difficulty, 69 percent of cases (25 of 36) evolved into a "cannot
intubate and cannot ventilate" situation. A definitive airway was eventually secured in 79 percent
of all 98 reported claims. In the claims involving an anticipated difficulty, 89 percent of cases
succeeded in securing an airway. Help was either not called for or was unavailable in 7.5 percent
of all claims. Of the claims with an anticipated difficulty, help was either not called for or was
unavailable in just one claim.

The study about the use of monitored anesthesia care (MAC) by American society of
anesthesiology shows that Comparison of MAC Claims to GA and RA Claims of 1,952 claims
for surgical anesthesia in the analysis, 121 claims (6%) were associated with MAC, 1,519 (78%)
were associated with GA, and 312 (16%) were associated with RA.). One fifth of MAC claims
occurred during eye surgery, and one fifth occurred during reconstructive or plastic surgical
procedures in the head and neck areas, in contrast to GA) or RA claims. The severity of injury
for MAC claims was similar to that for GA claims, with a similar proportion of death and
permanent brain damage (12).
12
Death and permanent brain damage were more common and temporary injuries were less
common in MAC claims compared with RA claims. A respiratory damaging event led to an
adverse outcome in similar proportions of MAC and GA claims but a significantly smaller
proportion of RA claims. Inadequate oxygenation/ventilation was the most common specific
respiratory damaging event in MAC claims. Equipment-related damaging events also occurred
more commonly in MAC claims than in RA claims. Cautery fires were the most common
equipment problem in MAC claims. These are described in more detail below. Inadequate
anesthesia or patient movement during surgery was the primary damaging event responsible for
11% of MAC claims but only 3% of GA claims and 2% of RA claims. Most MAC claims (83%)
associated with inadequate anesthesia or patient movement resulted in eye injury during eye
surgery or eye block administration (12).

In Maryland, all claims against health care provider in excess of $20,000 must be filed with the
Office of Health Claims Arbitration. During the study period, 70% of the claims were filed
against anesthesiologists,17% were against nurse anesthetists, and 13% named both the
anesthesiologist and the nurse anesthetist. Of the claims filed against CRNAs, 55.5% were based
on the inability to adequately monitor patient status, while 22.2% cited failure to obtain or
maintain an airway. Joint liability was alleged for inability to adequately and safely establish an
airway (43%), problems monitoring patient status (43%), and ineffectively administering
anesthesia (14%)Death occurred in 22% of the anesthesiologist-based claims. Nerve damage and
back or spinal cord injuries accounted for the next most frequent basis for claims, each
accounting for 13% of cases. Airway trauma (8%) and infection/sepsis (8%) were also reported
in the anesthesiologist claims. (9)

A study in Saudi Arabia from total 1765 litigation claims studied between (1420-1424H 1999-
2003 AD) from available total of 2970 cases filled for processing, were reviewed. Most of claims
originated from Saudi nationals (86.3%) claims and from non-Saudi expatriates (13.7%).
Anesthesia-related malpractice claims consisted of 76 cases (3.8%) of the total number of claims
referred to the MLC, involving 80 anesthesiologists 72 (90%) males, and eight (10%) females
(13).
13
Neuraxkial deficits resulting from regional anesthesia techniques is considered the second
common cause, but with a wide range of consequences ranging from simple as transient
neurapraxia, up to permanent loss of function resulting from peripheral nerve damage or spinal
cord injury (13). Nonetheless, law ranking and poor setup of the medical facilities play an
important role in the increased incidence for litigations. Data analysis revealed that the MOH and
private sectors contributes more than 90% of the total number of claims that were referred to the
MLC (13).
Aspiration was considered the primary damaging event in five cases, of which three cases did not
follow the standard preoperative fasting time. During the last decade, policy and practice
regarding 'nothing by mouth' (NPO) status before elective surgery have been relaxed, especially
with regard to clear fluids. However, it is notable that the latest ASA guidelines maintain a NPO
time of more than 6-8 hr for solids before elective surgery, and this has been accepted rigidly in
our courts. (7)

2.2. Responsibilities of the anesthetist toward his patients

Preoperative visitation and evaluation of the patient.

He should discuss with the patient any previous anesthesia experiences, and all drug
idiosyncrasies, and mention the anesthetic agent and technic which will probably be used if no
unexpected circumstance arises. He should instill a feeling of confidence and security in the
patient, but with a knowledge that some risk is involved. "A written consent, preferably with a
witness, is mandatory." Frequently the cause of loss of a suit by an anesthesiologist is failure to
have evidence of a preliminary examination on the patient's chart.

The anesthesiologist also should note all information on the chart. Included in the preoperative
report is evaluation of any chronic bronchitis, pulmonary fibrosis, coronary artery disease with or
without myocardial involvement, or vascular disease. The record should include any history of
headache, backache, hoarseness, or previous complications with anesthesia. Insufficient
14

laboratory data can also cause the defendant to lose a malpractice suit. The nutritional status, the
last time the patient ate or drank, and the presence of dental restorations, etc., should be
recorded.

Anesthetic administration and intraoperative monitoring

It is the anesthesiologist's responsibility to prevent, correct, or minimize physiologic aberrations
of the vital systems of the body. The anesthesiologist, up to the time the patient is well along the
road to recovery, faces unlimited potential hazards. He must be sure his equipment and apparatus
are in proper working condition. Before beginning anesthetization, the base line of pulse, blood
pressure and respiration must be recorded.

The patient must be strapped securely on the operating table to prevent his falling. Malposition
of the patient during anesthesia may cause brachial plexus damage; hyper abduction of the arm
can cause nerve palsy. Prolonged steep Trendelenburg position may result in shoulder and wrist
injuries; a dangling foot or arm can result in foot or wrist drop. The careful support of the
unconscious patient and the padding of all points exposed to pressure are prophylactic measures.
Patients must never be unattended while in the operating room; a third person, preferably a
nurse, must be present if the patient is a female. (15)

They have to do with induction and maintenance of anesthesia, improper protection of the eyes,
improper use of instruments, over dosage, giving the wrong drug, excessive pressures, etc. are
sources of danger to the patient which can result in legal action. (15) The anesthesiologist must
make certain that the patient has a free airway during transit and arrival in the recovery room or
ward, and is in the best physiologic condition that his state of consciousness permits. He himself
must insure the patient's safe delivery to his ward. (15)

There was a strong positive relationship between successful outcome (no harm or prolonged
hospitalization without injury) in patients monitored with standard monitoring and unsuccessful
outcome (death or permanent neurologic injury) in patients whose reports specifically stated that
no physiologic monitoring was used. In the Western World, lawsuits against intraoperative
awareness are not uncommon with its psychological drawbacks on patients in the postoperative
15

period (13).
2.3. COUSE OF PERIOPERATIVE MALPRACTICE
Nonetheless, law ranking and poor setup of the medical facilities play an important role in the
increased incidence for litigations. Data analysis revealed that the MOH and private sectors
contributes more than 90% of the total number of claims that were referred to the MLC. The
MOH hospitals or small clinics cover most of the small cities and that most of these facilities are
run by under-trained and under-staffed physicians together with inadequate equipment and
supplies, a fact which renders such facilities more prone for malpractice and litigations (13).

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Chapter 3 OBJECTIVES

3.1 General Objectives

The overall objective of the study is to assess the perioperative malpractice of anesthetist under
anesthesia in Ras Desta memorial generalized hospital Addis Abeba Ethiopia.

3.2 Specific objectives

The specific objective of this study included the following
1. To determine factors associated with perioperative malpractice of anesthetist.
2. 2.To identify type of perioperative malpractice of anesthetist in Ras Desta memorial
generalized hospital, if any.
3. To differentiate at which stage of perioperative
4. Based on the analysis to provide recommendation and reference

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Chapter 4 Methods and Materials

4.1 study Area and Study population

This study was conducted in Ras Desta memorial Specialized hospitals) in Addis Ababa – the
capital city of Ethiopia. Addis Ababa is the largest city in Ethiopia with a population of
3,384,569 according to the 2007 population census in an estimated area of 530.14 square
kilometer. In the city there are 11 hospitals have functional operation room and out of this 5 are
Federal Hospitals. People from different regions of Ethiopia come to those hospitals to get
specialized services. Currently Ras Desta gives surgical services in the following departments,
obstetric, Urological surgery, ENT surgery and orthopedic surgery. This study was conducted
from March 30- June 11, 2018 G.C at Ras Desta hospital in Addis Ababa, Ethiopia.

The study population for this study was all anesthetist who are operating in the Hospital and all
elective and emergency procedure (minor, major, surgery, gynecology, obstetric and
ophthalmology) that will be proceed upon under anesthesia during the study period will be
observed.

4.2 Sample size and sampling Techniques

The data was gathered through both primary and secondary methods of data collection
techniques. The primary data collection techniques were survey method through questionnaire
and observation methods. The secondary data was anesthesia sheets, different articles, related
studies, books and other related materials.

The sample size of the study was the total anesthesia who are operating in the Hospital so,
instead of using a sample to get the population we preferred to use Census method in which all
the population are part of the study. Observational study was employed in all elective surgical in
patients who undergo surgery during the study period.
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4.4 Method of Data collection
In order to see the inter relationship of the specified variables both primary and secondary source
of data was employed. Observation, structured questionnaire from anesthetist was used as a
primary data collection tool.

Questionnaire: The questionnaires was distributed to the target population and designed by using
lacerate Scale but it was varying on the type of question. The questionnaires were prepared in
English

Personal observation: is the other primary source of data which is versatile approach to data
collection and also it is an efficient way to collect data when the researcher is interested in
studying real time practice and evidence. We observed the practice by going to Ras Desta
Hospital two days (Monday and Wednesday) among the week days in which number of elective
patient who programed for surgery are increased.

Secondary data the researchers tried to refer different books, published and unpublished
documents, journals, articles and research papers to get information on the theoretical frame
work of the study. The following variables was included in the study.
1. Preoperative patient assessment.
2. Proper use of anesthesia equipment.
3. Proper use of anesthetics.
4. Monitoring

4.3 Method of Data Presentation, Analysis, and Interpretations

After the necessary information collected from different respondent the data, was coded and

edited the researchers used descriptive analysis by using percentage and frequency in tabular

forms, finally the data was analyzed and interpreted.

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4.5 Data quality assurance
During data collection both principal investigator and data collector will check for the

completeness of the information needed. Furthermore, the data will be also check for its

completeness during analysis. After each day of data collection principal investigator will stored

data in a secure place.

4.6 Ethical Consideration

Prior to any data collection, ethical approval will be obtained from Minilik II Health Sciences

College ethical review committee/board. Oral informed consent will be obtained from the study

subjects/study population and the aim of the research will be clearly depicted to the Anesthetist.

But those who will not be voluntary to give consent will be excluded from the study. In doing so,

confidentiality will also be ensured by avoiding personal identifications, keeping questionnaires

and checklists locked.

4.7 Dissemination of results

The study result will be disseminated to Minillik Health science college Anesthesia department

and Library.

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CHAPTER FIVE DATA PRESENTATION ANALYSIS AND INTERPRETATION

5.1. Data presentation analysis and interpretations

The data collected through questionnaire and observation were presented together. In the first
part the data collected from the respondents were the general information and next the detailed
Anastasia malpractice core variables. The questionnaire was distributed to 9 anesthetists and all
were returned. The total number of anesthetists in the hospital is 12 but we only get 9
respondents. Students are already completed their practice work so that the questionnaire were
not distributed to students.

Demographic characteristics of respondent

Among the respondents 44.4% were male and the remaining 55.6% are female. Regarding the
age of the study participants 43.75% were below the age of 30; 56.25% between the age of 30
and 35 and all respondents are BSc anesthetist.

Q1. Many study show that there is perioperative malpractice in the field of
anesthesia.

Options Frequency Percentage

Strongly Agree 2 22.2
Agree 3 33.4
Neutral 2 22.2
Disagree 2 22.2
Strongly Disagree 0 0
Total 9 100%

Assessment of perioperative malpractice of anesthetist were addressed as strongly agree, agree,

neutral or disagree. In the question many study show that there is perioperative malpractice in the
field of anesthesia from 9 (22.2%) anesthetist strongly agreed,9 (33.4%) agreed, 9(22.2) neutral
and disagree 9(22.2). In this study, almost 60% of anesthetists are agreed.
21

Q2. Do you fear to sue because of malpractice claim?

 Options Frequency Percentage
Yes 7 77.8
No 2 22.2
Total 9 100%

As shown in the above table 77.8% of the response implies that they fear to sue because of
malpractice claim and 22.2% are implies no fear.

If your answer in the above question is ‘yes’ what do you do to prevent yourself?

For this question most of respondents imply as “I’m try to avoid malpractice, I took proper
anesthesia note intraoperatively.

Q3. Do you check the anesthesia machine and equipment based on master
plan?
Options Frequency Percentage
Always 5 55.5
Sometimes 4 44.5
Every Monday Morning 0 0
Usually 0 0
Total 9 100%

The respondents were asked do you check the anesthesia machine and equipment based on
master plan. Among all 55.5% response shows they did always, 44.5% sometimes, 0% every
Monday, and also 0% usually.

Q4. In which time you choose to prepare airway equipment and drug?
Options Frequency Percentage
Based on Schedule 6 66.7
After the patient is evaluated 1 11.1
When the patient is in the OR 2 22.1
Total 9 100%
22
For the question “In which time you choose to prepare airway equipment and drug” majority of
respondents 6(66.7%) was replied as based on schedule, 2(22.2%) are prepare airway equipment
and drug When the patient is in the OR while 1(11.1%) are after the patient is evaluated.

Q5. Did you face the “can’t intubate ““can’t ventilate” scenario in
unanticipated difficult airway?
Options Frequency Percentage
Once in my life 0 0
Sometimes 2 22.2
Many times 0 0
No 7 77.8
Total 9 100%

For the question “Did you face the “can’t intubate ““can’t ventilate” scenario in unanticipated
difficult airway” almost 7(78%) are not face can’t intubate can’t ventilate situation, 2(22.2%)face
sometimes.

Q6. It’s difficult to say the consent always taken by anesthetist is well informed.
Options Frequency Percentage
Strongly Agree 4 44.4
Agree 4 44.5
Natural 0 0
Disagree 1 11.1
Strongly disagree 0 0
Total 9 100%

For the question “It’s difficult to say the consent always taken by anesthetist is well informed”,
4(44.4%) strongly agreed, 4(44.4%) agreed, and 1(11.1%) disagreed. The overall value shows
that almost 90% of respondents agreed that the consent they always took is not well informed.

Q7. Is your institution fulfilling all equipment that you need to manage difficult
airway?
Options Frequency Percentage
23

Yes 3 33.3
 No 6 66.7
Total 9 100%

If your answer in the above question is ‘No’ what airway equipment you like to have?

For this question almost all respondent who say yes are need to have all emergency drugs from
simple laryngeal mask airway up to fiber optic. This implies they haven’t at list laryngeal mask
airway which is the most life saver airway equipment in can’t intubate scenario.

we also observed this shortage of equipment’s most of the time their common management
strategy was persistent nonsurgical attempts.

Q8. How do you get your preoperative patient assessment and evaluation
related to the standard?
Options Frequency Percentage
Excellent 3 33.3
Very good 2 22.2
Good 4 44.5
Total 9 100%

For the question “How do you get your preoperative patient assessment and evaluation related to
the standard” 4(44.5%) are replies good, 2(22.2%) very good and 3(33.3%) are evaluate their
preoperative patient assessment excellent. According to the standard preoperative patient
assessment the anesthetist should instill a feeling of confidence and security in the patient by
giving the necessary explanation about the procedure that include the risk and benefit of surgery.

But we observe that no anesthetist can explain about any command they give for the patient. For
example, the patient should understand why he should keep NPO or he needs adequate
explanation about the risk of not keeping NPO and also the benefit.

Q9. Many anesthetist use estimations to calculate dose of anesthetics.

Options Frequency Percentage
Strongly Agree 0 0
24

Agree 7 77.8
Natural 0 0
 Disagree 0 0
Strongly disagree 2 22.2
Total 9 100%

Assessment of malpractice were addressed as strongly agree, agree, neutral, disagree and
strongly disagree for the question “Many anesthetist use estimations to calculate dose of
anesthetics” most of respondents 7(78.8%%) are agreed,2(22.2%) strongly disagreed. This
implies in appropriate use of anesthetic dose or using estimation almost become norm.

Q10. Which monitoring is functional most of the time?

1. ECG.
2. Capnography.
3. Bp apparatus.
4. Thermometer.
5. Pulsoxymeter.

For the question “which monitoring is functional most of the time” almost 90% of respondents
said only blood pressure apparatus and pulse oximetry are functional while 1(11.1%) said only
pulse oximetry is functional. This implies the other three basic intraoperative monitorings (ECG,
Capnography and Thermometer) are not functional. According to WHO recommendation the
above five monitoring are put as at list they should available be functional and also should be
used for every patient..

There was a strong positive relationship between successful outcome (no harm or prolonged
hospitalization without injury) in patients monitored with standard monitoring and unsuccessful
outcome (death or permanent neurologic injury) in patients whose reports specifically stated that
no physiologic monitoring was used.

Q11. Which monitoring you use for every patient?

1. ECG.
2. Capnography.
3. Bp apparatus.
25

4. Thermometer.
 5. Pulsoxymeter.

From the above question “12” we understood only pulse oximetry and blood pressure apparatus
are functional from those 7(77.8%) of respondents use only blood pressure apparatus and
2(22.3%) are used only pulse oymetry. This implies that no one uses capnography, ECG and
thermometer.

Capnography is the measurement of expired CO2 and has become increasingly popular as a
diagnostic tool in a number of settings. It is now the confirmation method of choice in anesthesia
for proper placement of an endotracheal tube, monitoring changes in mechanical function of the
lung is vital in developing a safe and effective support strategy in the face of respiratory failure.
In a mechanically ventilated patient, construction of pressure-volume (PV) curves can provide
important information about mechanics and help guide ventilator management. Inadequate
oxygenation/ventilation was the most common specific respiratory damaging event.

We also observed this monitoring are not used by anesthetist the amazing thing is almost all
anesthesia machine have those monitoring. The reason behind why they haven’t use those
monitoring is not known.

Q12. For what type of patient you make ready emergency drugs?
Options Frequency Percentage
For critical ill patient 1 11.1
For geriatrics 0 0
For pediatric 0 0
For obstetric 0 0
For all scheduled patient 8 88.9
Total 9 100%

The data in the above table indicates that almost 90% of the respondents Saied that they made
ready emergency drug for all type of patients and the remaining 10% indicates that they used
emergency drug only for critically ill patients. This indicates that the hospital almost made ready
emergency drug for all type of patients but the ten percent is also significant in terms of health so
it needs to be ready in all type of cases.
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13Q. Do have the norm of assessing the patient in recovery or in ICU
postoperatively?
Options Frequency Percentage
Yes always 5 55.6
Yes sometimes 3 33.3
Based on the patient status 1 11.1
4yes if I have time 0 0
Total 9 100%

For the above question “Do have the norm of assessing the patient in recovery or in ICU
postoperatively” 5(55.5%) yes always,3(33.3%) yes sometimes, 1(11.1%) are said based on the
patient status.

Q14. In your opinion from the list below which perioperative malpractice is
responsible for most complications?

Options Frequency Percentage

Inadequate pre-op assessment and preparedness 6 66.7
Lack of intra-op vigilance. 3 33.3
Because of skill and knowledge gap. 0 0
Enable to monitoring the patient continuously. 0 0
Shortage of equipment and drugs. 0 0
Total 9 100%

For the question “In your opinion from the list below which perioperative malpractice is
responsible for most complications”. Inadequate pre-op assessment and preparedness is account
6(66.7%), 3(33.3%) lack of intra-op vigilance, the remaining three are not chosen by
respondents. Inadequate anesthesia or patient movement during surgery was the primary
damaging event regarding to lack of proper intraoperative monitoring. Aspiration considered the
27

primary damaging event because of they did not follow the standard preoperative fasting time
due to inadequate preoperative information and understand.
28
Chapter Six Conclusion and Recommendations

6.1. CONCLUSION
The purpose of this research was to investigate perioperative malpractice of anesthetist. Based on
the findings the following conclusions are drawn. Most of the respondents are good in preparing
to manage any intraoperative complication by making ready an emergency drug for all schedule
patients. But the overall value beyond preoperative “well informed” consent shows that the
consent they always took is not “well informed”. According to the standard of preoperative
patient assessment the anesthetist should instill a feeling of confidence and security in the patient
by giving the necessary explanation and information about the procedure that include the risk
and benefit of surgery.

Based on the analysis of the questionnaires Inadequate pre-op assessment and preparedness and
lack of intraoperative vigilance are the most cause that responsible for most perioperative
complications. According to the American society of anesthesiology the preoperative patient
evaluation was found below the standard. It is the anesthesiologist's responsibility to prevent,
correct, or minimize physiologic aberrations of the vital systems of the body.

There are different factors that contribute for practicing below the standard like, Shortage of
equipment and materials, practicing the traditional norm.

29
6.2. RECOMMENDATIONS
Based on the results and the conclusions drawn in the above conclusion the following
recommendations are forwarded.

 The department will be better off if it tries to convince the management and the purchaser
to fulfill the necessary equipment and materials by emphasizing their role.
 In order to develop better practice based on the standard it’s better to develop different
guidelines and algorithms to make the anesthetist familiar with the practice and the
management.
 Respondents use only blood pressure apparatus and pulse oymetry. This implies that no
one uses capnography, ECG and thermometer. According to WHO recommendation the
above five monitoring are put as at list they should available be functional and also
should be used for every patient. It will be good, if the fulfillment and functionality of
equipment’s are in the operation room towards the anesthesia side is evaluated and
checked by the association and by the Health bureau.

30
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