It’s Never Just a Block: An Analysis of Regional
Anesthesia Closed Claims
Maria Hirsch, DNAP, CRNA
Marjorie Geisz-Everson, PhD, CRNA, FNAP
Beth Ann Clayton, DNP, CRNA, FAAN
Bryan Wilbanks, PhD, DNP, CRNA
Mary Golinski, PhD, CRNA
Michael Kremer, PhD, CRNA, FAAN
Kelly Wiltse Nicely, PhD, CRNA
Anesthesia care increasingly includes use of regional
anesthesia techniques, either as a primary anesthetic
or to reduce the patient’s postoperative pain. Both
neuraxial anesthesia and peripheral nerve blockade
have several noteworthy functions. These functions
include diminishing sensory sensation to pain and
potentially producing a motor blockade, both of which
may facilitate the surgical procedure. The desire to
reduce reliance on opioid medications, protocols to
enhance and accelerate patient recovery from surgery,
and patient expectations all contribute to the likeli-
hood that use of regional anesthesia will continue to
gain popularity. As such, it is essential to understand
whether an association exists between regional anes-
O
ver the past several decades there has been
a proliferation in the volume of anesthet-
ics administered that include some form
of regional anesthesia.1-3 Reasons for this
increase in volume include avoidance of
complications traditionally associated with components
of general anesthesia, improved resource utilization,
and greater patient satisfaction.2 Regional anesthetic
techniques can provide excellent perioperative analge-
sia. Enhanced recovery protocols for a broad variety of
surgical procedures increasingly recommend the use of
regional anesthetics to help accelerate patient recovery
and improve clinical outcomes.4 The impact of regional
anesthesia on anesthetic outcomes has been variably
described, with recent studies demonstrating improved
patient outcomes when regional anesthetics are used.1-3
The use of ultrasound guidance for the placement of
peripheral nerve blocks, when feasible, has contributed to
the consistency with which successful regional anesthet-
ics are obtained.5
Although no outcomes studies to date have dem-
onstrated the impact of regional anesthesia on overall
anesthetic mortality,6 historically, regional block–related
anesthesia malpractice claims are consistently repre-
sented in overall anesthesia malpractice claims.7 The
www.aana.com/aanajournalonline AANA Journal
thesia and adverse outcomes of care. The American
Association of Nurse Anesthetists Foundation Closed
Claim Research Team searched the most current data-
base of closed claims that involved adverse outcomes
when either a peripheral nerve block or a neuraxial
block was a component of care in the claims. Although
there were only 32 claims in the dataset, a thematic
analysis resulted in the identification of 3 themes:
errors in cognitive decision making, ineffective com-
munication patterns, and production pressure.
Keywords: Closed claims, malpractice, neuraxial block,
peripheral nerve block, regional anesthesia.
frequency of malpractice claims related to regional blocks
continues, in contrast to the declining overall rates of
complications related to anesthesia.7 Achievement of
optimal outcomes during use of regional anesthetics
entails application of the necessary knowledge, skills,
and abilities to perform these techniques consistent with
current standards of practice, as well as avoidance of
the issues that were identified through analysis of the
regional claims reported here. The purpose of this study
was to identify factors that may influence poor outcomes
in patients undergoing regional anesthesia.
Methods
A team was assembled to analyze closed claims related to
regional anesthesia found in the American Association of
Nurse Anesthetists Foundation (AANAF) closed claims
database. The team was composed of Certified Registered
Nurse Anesthetists (CRNAs) who were clinical practitio-
ners or educators. The team leader queried the AANAF
closed claims database for claims related to regional
anesthesia. The database includes both quantitative and
qualitative data consisting of 245 malpractice claims con-
sidered closed and involving either a CRNA or a student
registered nurse anesthetist from the years of 2003 to
2012.8 The query produced 32 claims related to regional
 October 2019  Vol. 87, No. 5 365
anesthesia. The allegations that comprised the basis for
these claims included failure to appropriately monitor
the patient following placement of a regional block, im-
proper regional anesthesia technique, inadequate docu-
mentation, and failure to identify complications in a
timely manner.
A descriptive analysis using statistical software (SPSS
version 19, SPSS Inc) and a thematic analysis of the 32
claims were conducted. Coding and subsequent theme
development was prompted by the 4 distinct sections
of the closed claims data collection instrument, includ-
ing the reviewer’s narrative, reviewer’s assessment, list
of accusations specific to each claim, and description
of lessons learned. Adherence to accepted principles of
qualitative research was maintained. Detailed descrip-
tions regarding the generation of the AANAF closed
claims database and thematic analysis used in this project
can be found in separate articles.8,9
Results
Evaluation of the 32 claims related to regional anesthesia
revealed that 75% of the claimants were female (n = 24),
with a mean age of 41 years. Most patients were identified
as physical status class 2 or 3. The regional anesthetics
were placed primarily in the surgery suite (n = 13) or in
labor and delivery (n = 12). Obstetric, ophthalmologic,
and orthopedic procedures were the most prevalent types
of procedures associated with regional anesthesia closed
claims (Figure 1). Ten claims were deemed preventable,
3 were deemed nonpreventable, and preventability could
not be determined in 19. The severity index (SI) associ-
ated with each claim was established; 9 injuries resulted in
death, and 15 injuries resulted in some degree of perma-
nent injury. Figure 2 shows the SI of all 32 claims. Twenty-
four claims (75%) resulted in monetary disbursements to
the claimants and ranged from $5,803 to $950,000 (mean
= $278,404). The legal allegations that served as the basis
for the claims are summarized in Table 1.
Thematic analysis of the 32 claims yielded 3 overarch-
ing themes: errors in cognitive decision making, ineffec-
tive communication patterns, and production pressure.
These themes were related to the provider, the patient,
or the healthcare environment; all identified themes are
shown in Table 2. Several individual claims encompassed
more than 1 theme.
• Errors in Cognitive Decision Making. Greater than
50% of the claims involved errors in cognitive decision
making. Errors in cognitive decision making included
gap in care, missed opportunities to identify regional
anesthesia–related complications, failure to identify and
treat acute physiologic deterioration in a timely manner,
lack of use of available technology, and lack of accept-
able decision making. An example of gap in care was
described when a patient received both midazolam
and fentanyl before placement of a retrobulbar block.
366 AANA Journal  October 2019  Vol. 87, No. 5 www.aana.com/aanajournalonline
Figure 1. Types of Procedures Related to Regional
Anesthesia Claims
Unfortunately, the block was performed without any
monitors or supplemental oxygen; the anesthesia record
indicated the total anesthesia time for the block was 7
minutes. A second CRNA retrieved the patient for surgery
approximately 16 minutes later and discovered that the
patient was apneic and unresponsive. Documentation is
lacking as to who was responsible for care during the
interval between placement of the block and arrival of
the second CRNA. The patient was resuscitated, and
spontaneous circulation eventually returned. However,
the patient never regained consciousness. Life support
was ultimately discontinued, and the patient died.
Claims also involved missed opportunities to identify
regional anesthesia–related complications, and treatment
therefore was delayed. Examples of this phenomenon
were in the diagnosis of a spinal cord hematoma, epi-
dural abscess, and meningitis. One claim involved the
formation of an epidural abscess following placement of
an epidural block for labor and delivery analgesia. The
patient’s back was prepared with betadine and not the rec-
ommended chlorohexidine.7 The epidural block was suc-
cessfully placed after 2 attempts and used for both labor
and subsequent cesarean delivery (due to failure of labor
to progress). Twenty-four hours after delivery, the patient
experienced a rash on her back. The CRNA attributed the
rash to adhesive tape, and there was no follow-up. The
patient returned to the hospital 5 days after discharge
with a fever and back and neck pain. Treatment was initi-
ated for an Escherichia coli infection at the incision site,
and she was discharged. The neck and back pain were
not addressed. Fourteen days later, a magnetic resonance
image (MRI) revealed an extensive epidural abscess re-
quiring a surgical laminectomy. The patient sustained
permanent central and peripheral nerve deficits.
An example of lack of acceptable decision making
involved a patient with multiple comorbidities who
was scheduled for an elective cosmetic procedure in the
prone position and at a freestanding surgical facility. The
patient’s medical and surgical history included chronic
low back pain, probable (unconfirmed) obstructive sleep
apnea, and previous lumbar spine surgery. The patient
chose the type of anesthesia desired, and the CRNA
Figure 2. Severity Index for Regional Closed Claims

Lawyer’s allegation Number of occurrences

Failure to ensure that patient is appropriately monitored after regional anesthesia 6
Improper regional anesthesia technique 5
Inadequate documentation (vital signs and events) 4
Failure to identify complication and treat in a timely manner 4
Anesthesia technique led to eye perforation 4
Failure to interview patient appropriately to elicit all needed information 3
Persisting with epidural placement despite multiple previous “wet taps”/attempts 3
Inadequate informed consent 2
Retained epidural catheter tip 2
Oversedation of patient during regional anesthesia resulting in loss of airway 2
Spinal cord hematoma caused leg paralysis 1
Failure to follow infection control standards 1
Labor epidural and spinal anesthesia caused foot drop 1
Psychological trauma caused by inadequate anesthesia 1
Selection of epidural anesthesia with previous back surgery 1
Failure to modify plan based on patient response 1
Failure to consider unique needs of patient when developing anesthetic plan 1
Wet tap during epidural anesthesia caused cerebral meningitis 1
Failure to use fluoroscopy or x-ray guidance for epidural steroid injection 1
Inappropriately anesthetizing a morbidly obese patient (BMI = 42 kg/m2) in 1
an outpatient surgery center
Wrong medication administered into epidural space (magnesium vs lidocaine) 1
Complications from facial nerve block resulting in temporomandibular joint pain 1
Total 47

Table 1. Legal Allegations Related to Regional Anesthesia Malpractice Claimsa

Abbreviation: BMI, body mass index.
aThese are the allegations identified in this study used to initiate a medical malpractice lawsuit. The total number of allegations is
greater than the number of reviewed cases because many of the allegations occurred simultaneously.

complied with the wishes for an epidural block. After
the CRNA’s 2 attempts at block placement and both
times eliciting cerebrospinal fluid, a second CRNA was
successful with placement, and results of a test dose of
lidocaine with epinephrine were negative for changes
in heart rate. The first CRNA resumed care of the
patient and administered lidocaine and 2-chloroprocaine
through the catheter. In the operating room the patient
was assisted into the prone position for the procedure.
During the procedure, the oxygen saturation decreased,
and the patient’s head and airway were repositioned
with anticipation of relieving apparent airway obstruc-
tion. Despite this maneuver, desaturation was noted via
pulse oximetry. The CRNA was unable to adequately
ventilate the patient in the prone position; therefore, the
patient was quickly turned supine, endotracheal intuba-

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 Theme Descriptors
Errors in cognitive decision making Lack of continuity of care/gap in care; delayed treatment/failure to recognize/knowledge
deficit; poor decision making
Ineffective communication patterns Patient failure to disclose; communication between providers
Production pressure Departure from standards of care; resource allocation; inappropriate patient selection for
type of facility
Table 2. Themes and Descriptors Related to Regional Closed Claims
tion was performed, and the case was canceled. Both
lower extremity sensation and motor function was slow
to return; the patient was transferred to the hospital for
further evaluation. The MRI revealed a pneumocephalus,
and a diagnosis was made for cauda equina syndrome.
Rehabilitation ensued for lower extremity motor/sensory
deficits and poor bladder/bowel control. The patient
eventually regained some lower extremity function but
ultimately was found to have permanent disability.
• Ineffective Communication Pattern. Evidence of
ineffective communication patterns was found to occur
between patients and the CRNA, between anesthesia
professionals, and between anesthesia professionals and
other members of the perioperative team. An example
of this theme involves a parturient who requested labor
epidural analgesia. There was a failure on behalf of the
patient to inform the CRNA of her history of spina bifida
as an infant and a previous surgical procedure to remove
a spinal tumor. The patient had informed the anesthesi-
ologist of her previous surgery for spinal tumor removal
and spina bifida; however, there was no communication
between the anesthesiologist and the CRNA. The CRNA
asked the patient about the cause of a scar on her back.
The patient communicated to the CRNA that the scar was
the result of a lumbar laminectomy. After several unsuc-
cessful attempts to place the epidural by the CRNA, the
patient informed the CRNA about the previous spinal
tumor and spina bifida. There were no further attempts
at placement made; however, after a natural childbirth
(no anesthesia), a diagnosis of paraplegia was made. This
case represented communication failures between anes-
thesia providers and between the CRNA and patient.
• Production Pressure. Gaba et al10 described produc-
tion pressure as the pressure to put efficiency, output, or
continued production ahead of patient safety. Production
pressure was found to be a factor in almost one-third of
the regional anesthesia claims and involved deviations
from the AANA Standards for Nurse Anesthesia Practice
(AANA Standards), inappropriate patient selection for
facility, and inappropriate staffing. Lack of informed
consent, inadequate/missing preanesthetic evaluation,
poor documentation, and failure to monitor the patient
represented the most common violations of standard of
care. Table 3 shows frequently violated Standards for
Nurse Anesthesia Practice found in the claims.
Production pressure, inappropriate patient selection
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for the facility, and subsequent deviations from the prac-
tice standards are described in a claim involving a young,
morbidly obese (body mass index of 42 kg/m2) individual
with multiple comorbidities including obstructive sleep
apnea. The patient was scheduled for a lower extremity
orthopedic procedure in a freestanding surgical facility.
The CRNA had reservations about providing anesthesia
for the patient in this setting but agreed to proceed. A
spinal anesthetic was placed, and intravenous sedation
was facilitated with a propofol infusion. During the
anesthetic both hypotension and airway obstruction
occurred. The patient’s airway was intubated to relieve
the airway obstruction, and vasoactive medications were
administered to counteract the hypotension. Details of
care were not adequately documented, and it was diffi-
cult to ascertain when vasoactive medications were given
or if there was any response to them. Furthermore, the
medical record was appended on the second and fourth
postoperative days (however, this did not offer clarity to
the sequence of events). The patient ultimately received
a diagnosis of anoxic encephalopathy and died less than
2 weeks after the surgery.
Another claim is worth noting here. A patient was
scheduled for cataract surgery in a freestanding surgical
facility. A CRNA administered a retrobulbar block to the
patient without connecting the patient to monitors, pro-
viding the patient supplemental oxygen, or documenting
vital signs. Once the block was complete, the CRNA left
the patient’s bedside without transferring care to another
provider. The CRNA who provided the block was not the
CRNA who was scheduled to provide anesthesia for the
procedure. The patient became apneic and unresponsive,
did not regain consciousness after resuscitation, and life
support was eventually discontinued. The pressure to do
many cases may have created a scenario in which lack of
patient monitoring and poor documentation were con-
sidered acceptable.
Another claim that appears related to production
pressure and to breech of standards involves a laboring
parturient who was accidentally given a wrong medica-
tion via her epidural catheter. A student registered nurse
anesthetist who “felt rushed” administered magnesium
sulfate instead of ropivacaine via the epidural catheter.
This error was not detected for several hours despite
numerous complaints of pain by the patient. Over the
course of 4 hours, the patient received 3 additional lido-
 Standard Abbreviated description
2 Perform and document or verify documentation of a preanesthesia evaluation.

4 Obtain and document or verify documentation of informed consent from patient or legal representative.

5 Communicate anesthesia care and activities through legible, timely, accurate, and complete documentation.

9 Monitor, evaluate, and document the patient’s physiologic condition as appropriate for the procedure and
anesthetic technique.

Table 3. Frequently Violated AANA Standards for Nurse Anesthesia Practice

Abbreviation: AANA, American Association of Nurse Anesthetists.

caine boluses and a new epidural catheter, none of which
resolved the patient’s pain. Finally, the epidural infusion
was discontinued in preparation for an MRI to evaluate
for an epidural abscess. When the patient was taken to
the radiology suite 4 hours later, the patient was unable
to move her legs, and the CRNA discovered magnesium
sulfate was the drug in the epidural pump. The patient
sustained permanent neurologic injury.
Discussion
Analysis of the data specific to anesthesia closed malprac-
tice claims offers the opportunity to acknowledge factors
that appear contributory to adverse outcomes. The ben-
efits are noteworthy irrespective of the type of anesthesia.
The themes identified in these regional anesthesia claims
were similar to those found in other anesthesia closed
claims studies.11-13 This finding suggests that although
the volume of regional anesthesia is exponentially in-
creasing, and for a plethora of sound scientific reasons,
it is not free from its own unique set of complications.
• Errors in Cognitive Decision Making. Errors in
cognitive decision making were found in more than half
of the claims. Frequently, these errors are attributed to
increased cognitive workload.14 Cognitive workload is
defined as the psychological effort necessary to complete
a particular task.15 Excessive cognitive workload can
result in information overload and healthcare profes-
sionals experiencing a decreased ability to process new
information.16 Information overload makes it challenging
for clinicians to separate relevant from irrelevant infor-
mation to inform optimal clinical decision making.17 If
information overload is sustained over time, it may cause
mental fatigue and contribute to cognitive errors (ie,
errors in decision making) that increase the likelihood
of medical errors.14 Excessive cognitive workload results
in medical errors,18-22 by decreasing vigilance and situ-
ational awareness.21,23
Situational awareness and vigilance are 2 interre-
lated concepts that are important in preventing errors in
cognitive decision making.24 The defining attributes of
situational awareness include an individual’s perception
of his or her surroundings, comprehension of his or her
observations, and initiating clinical actions based on that
comprehension.24 For example, situational awareness
involves a CRNA observing changes in a patient’s physi-
ologic condition, comprehending the implications of the
physiologic changes to formulate a corrective interven-
tion, and then actually implementing the intervention.
Vigilance is defined as sustained awareness during a single
task and is related conceptually to situational awareness.25
Vigilance is a prerequisite for situational awareness, but
situational awareness is not a prerequisite for vigilance.25
For example, a CRNA can be vigilant of a patient’s physi-
ologic vital signs but be unaware of surgical activity or
blood loss (ie, lack of situational awareness).
Cognitive biases can influence cognitive decision
making. A cognitive bias is a type of cognitive error
that results from faulty thought processes.26 The faulty
thought process can include an error in collecting or
processing clinical information.26 Cognitive biases that
result in medical errors are commonly caused by a
knowledge deficit.27 More than 100 types of cognitive
biases are currently described in the literature.27 A strat-
egy suggested in the literature to mitigate cognitive bias
is self-reflection to identify personal bias and incorrect
thought processes.26 Some examples of cognitive bias
relevant to anesthesia include diagnostic momentum,
framing, and anchoring.26 Diagnostic momentum occurs
during transfer of patient care when a new team assumes
care of the patient and accepts the previous clinician’s
diagnosis of a specific disease or complication, but no
new assessment is performed.26 Framing occurs when
a clinician makes assumptions based on current clinical
care being provided (eg, missing an internal hemorrhage
because the surgical procedure is not normally associ-
ated with it).26 Anchoring occurs when clinicians make
an assumption based on the patient’s medical history
(eg, patient with insulin-dependent diabetes must be
noncompliant with diet at home).26 It is important for
anesthesia providers to be aware of potential causes of
errors in cognitive decision making and to understand
how to mitigate them.
• Ineffective Communication Pattern. This analysis
cited ineffective communication as a causal factor in
several claims. Effective communication between health-
care team members and with patients is essential for the
provision of safe patient care. The Joint Commission es-
timates that approximately 80% of serious medical errors

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 Severe neuraxial
complication Signs and symptoms
Epidural abscess Onset 1-3 d; history of
infection; fever, malaise, back
pain; possible paresthesias,
flaccid paralysis, later spastic
Spinal hematoma History of anticoagulants;
sudden onset; sharp, transient
back pain and leg pain; variable
sensory involvement reflexes
Meningitis Nuchal rigidity, headache,
mental impairment
Direct spinal cord History of difficult spinal
trauma anatomy; sudden or occult
onset; paresthesia, especially
with injection; dermatomal or
diffuse paresthesia; possible
weakness
Table 4. Adverse Outcomes in Neuraxial Anesthesia
Abbreviations: CT, computed tomography; MRI, magnetic resonance image.
Potential
Diagnosis Treatment prevention
CT scan/MRI signs of Neurosurgical Chlorohexidine skin
extradural compression; consultation for preparation; maintain
rise in laboratory consideration of aseptic technique
inflammatory markers decompression
CT scan/MRI signs of Neurosurgical Identification of
extradural compression; consultation for neuraxial midline via
laboratory data display consideration of ultrasound guidance
clotting abnormality decompression
CT scan/MRI signs of Neurosurgical Chlorohexidine skin
extradural compression; consultation; preparation; maintain
laboratory data displaying antibiotic therapy aseptic technique
clotting abnormality
CT scan/MRI displays Neurosurgical Identification of
edema or hemorrhage, consultation intervertebral level
needle tract; laboratory with ultrasound
data normal guidance

occur due to miscommunication during the transfer of
care.28 Most commonly, communication failures occur
between different professional members of a team, such as
between the anesthesia provider and surgeon, or between
the surgeon and a nurse.29,30 Poor information sharing by
the team during the intraoperative care has been shown to
contribute to an increased risk of complications or death
regardless of a patient’s physical status class.31
Communication failures may be the result of con-
flicting communication styles, inattention to concerns/
failure to voice concerns, differing “world views,” or
even disruptive behaviors.32 Communication failures
between providers and patients or providers and family
also contribute to poor patient outcomes. A healthcare
provider may be highly technically skilled, yet ineffective
communication on his or her part may lead to patient
dissatisfaction or complications.33 An anesthesia provider
may fail to obtain a thorough preanesthesia history, con-
tributing to the selection of an inappropriate plan of care.
In some cases, a patient either withholds information or
does not understand the need to disclose all his or her
medical history.
A patient’s understanding of questions may be limited
by the technical jargon used by healthcare providers
when obtaining a history, resulting in an incomplete
clinical picture for the anesthetist. Babitu and Cyna34
found that nearly half of patients misunderstood 1 or
more terms during a preanesthesia assessment, and
that technical terms were used by all the anesthetists
observed. Patients presenting for anesthesia care are
typically stressed or anxious, hungry and/or thirsty, and
tired, or may be in pain or otherwise distracted during the
preanesthesia assessment. A thorough history is the basis
of any anesthetic plan. As anesthesia providers, we must
ensure that we are using effective communication skills
and allocating adequate time to these essential interac-
tions with patients.
Obtaining an informed consent requires that a patient
be given accurate and timely information regarding the
risks and benefits of all anesthetic options. Specifically,
with regional anesthesia, investigators have found that
patients wish to receive information about minor (eg,
nausea, urinary retention) complications as well as more
serious potential complications (eg, permanent neurolog-
ic injury, high spinal anesthesia) when informed consent
is obtained.35 Ideally, discussions about anesthetic-relat-
ed risks and benefits should occur when both the patient
and anesthetist can provide the attention needed to have
a meaningful exchange free from the distractions of pain,
anxiety, or production pressure. In many cases, regional
anesthesia is performed as an adjunct to general anesthe-
sia or is nonessential,11 mandating that communication
regarding risks and benefits is particularly prudent.
Methods to reduce the occurrence of communication
failures between care providers during handoff is the
focus of a 2017 Sentinel Event Alert issued by the Joint
Commission.36 The use of checklists and standardized
tools, training in teamwork and nontechnical skills, and
verbal readback or closed loop communication are all
suggestions to improve communication in healthcare.37
Increasingly, it has become accepted that formal instruc-
tion in interprofessional communication skills must be
included in healthcare education to improve patient
safety and satisfaction.38-40
• Production Pressure. As previously noted, produc-
tion pressure is the pressure to put efficiency, output, or
continued production ahead of patient safety.10 Recent
articles identify production pressure as a known factor

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 1. Perform a complete and thorough preanesthesia assessment, to include documentation of preexisting neurologic deficits.
2. Standard patient monitoring should be used both during and after performing regional anesthesia until patient has recovered from
the effects of sedation. In addition, intraoperative monitoring of patients undergoing regional anesthesia should include audible
alarms and appropriate vigilance.
3. Informed consent should include the benefits, risks, and possible complications of the regional anesthesia technique selected.
Patients should be offered all appropriate options for anesthesia, including the least invasive technique that is appropriate for the
patient based on his or her comorbidities and procedure.
4. Ensure the appropriate equipment and supplies are available to perform the anesthetic, to include a variety of needle lengths to suit
the patient’s size.
5. Anesthesia providers should have full knowledge of possible complications related to a regional anesthesia technique and monitor
the patient for the development of possible complications.
Table 5. Recommendations for Reducing Regional Anesthesia–Related Adverse Events and Risk

related to anesthesia delivery.41,42 A few examples of pro-
duction pressure include avoidance of case cancellations
and delayed starts of cases, proceeding with cases despite
inadequate preoperative evaluation and/or despite patient
comorbidities, rapid turnovers between cases, removal of
anesthesia monitors during emergence, lack of available
resuscitative equipment during regional anesthesia ad-
ministration, failure to monitor neuromuscular blockade
during administration of neuromuscular blocking agents,
and poor hand hygiene.10,41,42 When we are rushed, we
are more likely to cut corners or take shortcuts to save
time or money.41 Most of these examples also represent a
failure to follow AANA Standards of Practice.
Production pressure can influence clinical decision
making, such as failing to follow AANA Standards,
which may result in anesthesia mishaps.10,41,42 Failure
to follow AANA Standards was found in more than half
of the claims related to regional anesthesia. The most
common violation in this study was failure to monitor
(AANA Standard 9). In the entire AANAF closed claims
database, the most commonly violated AANA Standards
were Standard 3 (plan for anesthesia care) and Standard
9 (monitoring, alarms).8 It is crucial that CRNAs be cog-
nizant of and follow AANA Standards, which exist to help
ensure safe anesthesia practice.
Although errors in decision making and ineffective
communication may occur independently, it is worth-
while to note that production pressure likely contributes
to all the identified themes. Therefore, it is imperative
that a CRNA remains vigilant to the risk of patient harm
that may occur when experiencing increased production
pressure. Some suggested solutions to decrease produc-
tion pressure include to increase provider vigilance,
adopt and use standardized protocols, evaluate/reevaluate
one’s own work practices and adopt current evidence-
based practices, and place patient safety above all other
factors.10,41,42 Adoption of a culture of safety empowers
individuals to stop a procedure if they perceive that pro-
duction pressure is threatening patient safety.
• Lessons Learned. The analysis of this cohort of re-
gional anesthesia–related closed anesthesia claims offers
an opportunity to provide recommendations to improve
the safety of patient care. Table 4 offers recommendations
to improve the safety of patient care during neuraxial an-
esthesia. Some general recommendations to help prevent
adverse events and reduce risk in patients undergoing all
types of regional anesthesia are presented in Table 5.
Conclusion
The gaining popularity of regional anesthesia techniques,
either as the primary anesthetic or to manage surgical
pain, reinforces the importance of critical analysis of
adverse events related to these techniques. The decision
to use a regional anesthesia technique should receive
the same degree of consideration as administration of a
general anesthetic, and adherence to standards of prac-
tice should be maintained. Risks exist with all anesthetic
techniques. Thoughtful preparation, diligence, and ap-
propriate vigilance will help to ensure a safe experience
for patients undergoing regional anesthetic techniques.
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AUTHORS
Maria Hirsch, DNAP, CRNA, is the director of Anesthesia Services for the
Carilion Clinic in Roanoke, Virginia, and a clinical assistant professor for
the Virginia Commonwealth University Department of Nurse Anesthesia,
Richmond, Virginia. Email: mthirsch@carilionclinic.org.
Marjorie Geisz-Everson, PhD, CRNA, FNAP, is adjunct faculty at Johns
Hopkins University School of Nursing Baltimore, Maryland and per diem
CRNA at Benefis Hospital Great Falls, Montana.
Beth Ann Clayton, DNAP, CRNA, FAAN, is an associate professor of
clinical nursing and the Nurse Anesthesia Program director for the Univer-
sity of Cincinnati College of Nursing, Cincinnati, Ohio.
Bryan A. Wilbanks, PhD, DNP, CRNA, is an assistant professor at the Uni-
versity of Alabama at Birmingham School of Nursing, Birmingham, Alabama.
Mary Golinski, PhD, CRNA, is an assistant professor in the School
of Nursing at Oakland University in Rochester, Michigan. She also is the
assistant program director for the Oakland University–Beaumont Graduate
Program of Nurse Anesthesia in Michigan.
Michael Kremer, PhD, CRNA, FAAN, is a professor at the Rush Univer-
sity College of Nursing and the codirector for the Rush Center for Clinical
Skills and Simulation in Chicago, Illinois. He has served on the AANA
Foundation Closed Claim Research Team since its inception in 1995.
Kelly Wiltse Nicely, PhD, CRNA, is the program director for the Nell
Hodgson Woodruff School of Nursing, Nurse Anesthesia Program, at
Emory University in Atlanta, Georgia.
DISCLOSURES
The authors have declared no financial relationships with any commercial
entity related to the content of this article. The authors did not discuss off
label use within the article.
ACKNOWLEDGMENTS
We wish to acknowledge Lorraine Jordan, PhD, CRNA, CAE, FAAN, and
the American Association of Nurse Anesthetists Foundation for supporting
this study and CNA Insurance Companies for providing data for this study.

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