Journal of Clinical Anesthesia 48 (2018) 15–20

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Journal of Clinical Anesthesia

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Original contribution

A medicolegal analysis of malpractice claims involving anesthesiologists in T

the gastrointestinal endoscopy suite (2007–2016)
Alexander B. Stone, MDa, Ethan Y. Brovman, MDa, Penny Greenberg, RN, MSb,
⁎
Richard D. Urman, MD, MBAa,
a
Brigham and Women's Hospital, Boston, MA, United States
b
CRICO Strategies, Boston, MA, United States

A B S T R A C T

Study objective: Gastrointestinal endoscopy cases make up the largest portion of out of operating room mal-
practice claims involving anesthesiologists. To date, there has been no closed claims analysis specifically fo-
cusing on the claims from the endoscopy suite. We aim to identify associated case characteristics and con-
tributing factors.
Design: Retrospective review of closed claims.
Setting: Multi-institutional setting of hospitals that submit data to the Controlled Risk Insurance Company
(CRICO) Comparative Benchmarking System, a database representing approximately 30% of annual malpractice
cases in the United States.
Patients: A total of 58 claims in the gastrointestinal endoscopy suite between January 1, 2007 and December 31,
2016.
Interventions: Gastrointestinal endoscopy procedures.
Measurements: We analyzed associated factors for each case as well as payments, and severity scores.
Main results: There was a difference in the percent of cases that resulted in payment by procedure type, with 91%
of endoscopic retrograde cholangiopancreatography (ERCP) cases resulting in payment compared with 37.5% of
colonoscopy cases, 25% of combined esophagogastroduodenoscopy (EGD)/colonoscopy cases, 21.4% of EGD
cases and 0.0% of endoscopic ultrasound cases (P = 0.0008). Oversedation was a possible contributing factor in
62.5% of cases. The mean payment for all claims involving anesthesiologists in the endoscopy suite was $99,754.
Conclusions: There are differences in the rates of payment of malpractice claims between procedures. ERCPs
made up a disproportionate percentage of the total amount paid to patients. While a significant percent of cases
involved possible oversedation, these errors were compounded by other factors, such as failure to resuscitate or
recognize the acute clinical change. With medically complex patients undergoing endoscopic procedures, it is
critical to have well prepared anesthesia providers.

1. Introduction screening and interventional gastrointestinal procedures for the fore-

Over the last decade, non-operating room anesthesia (NORA) has
been the major source of growth in number of anesthetics delivered and
currently makes up a significant fraction of the case load in many an-
esthesia practices [1–3]. A large proportion of NORA cases in the
United States are for gastrointestinal endoscopy procedures [4]. Ad-
vances in technology and procedural techniques allow for increasingly
complex procedures to be performed in the endoscopy suite, sometimes
in patients deemed too frail for the operating room [5]. The growing
elderly population ensures that there will be sustained demand for both
seeable future [6,7].
Previous analysis of the Anesthesia Closed Claims Project (ACCP)
database showed that malpractice claims for NORA cases have a high
rate of cases resulting in payment and larger median payments when
compared with operating room (OR) cases [4,8]. NORA cases also had a
higher proportion of claims involving the death of a patient compared
to claims from the OR [4,8]. The majority of NORA malpractice cases
occurred in the gastrointestinal endoscopy suite, which accounted for
38% of NORA malpractice cases in a 2009 analysis of the ACCP data-
base [8] and 51% of NORA malpractice cases in a 2017 study of the

⁎
Corresponding author at: Harvard Medical School, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, United States.
E-mail addresses: abstone@bwh.harvard.edu (A.B. Stone), Ebrovman@partners.org (E.Y. Brovman), PGreenberg@rmf.harvard.edu (P. Greenberg),
rurman@bwh.harvard.edu (R.D. Urman).

https://doi.org/10.1016/j.jclinane.2018.04.007
Received 1 March 2018; Received in revised form 13 April 2018; Accepted 15 April 2018
0952-8180/ © 2018 Elsevier Inc. All rights reserved.

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A.B. Stone et al.
ACCP database [4]. Prior ACCP analysis focused on oversedation, de-
monstrating that a predominance of claims (58%) involving over-
sedation involved anesthetics in the gastrointestinal (GI) endoscopy
cases [8]. Upper endoscopy and endoscopic retrograde cholangiopan-
creatography (ERCP) were overrepresented in the cases of oversedation
(93.3%) [8].
In the past 10 years, the practice of anesthesiology in the endoscopy
suite has expanded, and based on the ACCP analyses, the number of
malpractice cases citing anesthesiologists in GI cases has increased as
well [4]. To our knowledge, there have been no medicolegal analyses
that have specifically investigated cases involving anesthesiologists in
the gastrointestinal suite. To date, malpractice studies have grouped GI
endoscopy cases together as a subset of NORA cases, which eliminates
the nuances of a wide variety of procedures in this unique non-oper-
ating room environment. There is some concern that anesthesiologist-
provided sedation may be associated with worse outcomes during GI
procedures [9,10]. The goal of this study is to provide an updated
analysis of claims from the last 10 years, taken from a previously un-
reported, non-ACCP database. This is the first study specifically dedi-
cated to the analysis of anesthesia claims related to GI endoscopy, and
we aim to describe procedural factors that can lead to patient injury and
resultant claim against the anesthesia provider.
2. Methods
The Controlled Risk Insurance Company (CRICO) is a malpractice
insurance carrier that maintains an extensive database of medical
malpractice cases called the Comparative Benchmarking System (CBS).
The CBS database is a national database that contains over approxi-
mately 400,000 open and closed malpractice claims from Harvard-af-
filiated institutions, along with an additional approximately 400 aca-
demic and community hospitals and physician offices with over
165,000 physicians. The CBS represents approximately 30% of all
malpractice claims filed each year in the United States [11]. Cases that
are reported to the CBS do not overlap with the cases reported to the
ACCP. The Institutional Review Board (IRB) at the Brigham and Wo-
men's Hospital reviewed and approved this research study and the re-
quirement for written and informed consent was waived, as the CBS
database was already de-identified.
We queried the CBS database for the period between January 1,
2007 and December 31, 2016 for endoscopy cases where anesthesiology
was named the primary responsible service. Individual cases were also
reviewed by manual inspection of the case summaries. The variables
available from the CBS database included age, gender, indemnity paid,
location of the event, National Association of Insurance Commissioners
(NAIC) severity score, ICD-9 code for procedure, and CRICO-specific
coded fields for injury and contributing factors.
The NAIC severity score is a 0–9 standardized scoring system for
adverse events with 0 corresponding to no injury and 9 corresponding
to death [12]. For this analysis, “high severity” cases were rated 6–9
and represented permanent damage and death. Medium severity cases
were 3–5 and represented major temporary to permanent minor events.
Low severity cases were scored between 0 and 2.
Another variable available in the CBS database were contributing
factors that were determined by CRICO coders to have contributed to
the alleged event [11]. More than one contributing factor could be
coded for a given claim. For example, a claim could be identified as
being caused by deficits in technical skill as well as communication. The
contributing factor categories are listed in Table 1. Each broad con-
tributing factor category contained a series of subgroups. For example,
technical skill encompassed performance issues (poor technique, in-
experience with procedure etc.), as well as retained foreign bodies.
Clinical judgment included incorrect selection and management of
therapy as well as inadequate patient monitoring (failure to respond to
a clinical alarm or change in physiologic status), patient assessment
issues (failure to get an adequate history and physical exam) and failure
16
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Journal of Clinical Anesthesia 48 (2018) 15–20
Table 1
Contributing Factors as coded by CRICO. The denominator used for the percent
is of total cases (n = 58). An individual case could have multiple contributing
factors coded.
Contributing Factor Percent N
Technical skill 62.1% 36
Clinical judgment 48.3% 28
Communication 22.4% 13
Documentation 22.4% 13
Administrative 12.1% 7
Supervision of staff 8.6% 5
Patient behavior 8.6% 5
Equipment 1.7% 1
No factor coded 3.4% 2
to get a consult in a timely manner. Communication included failures in
communication between the team and family members (inadequate
informed consent, poor rapport) as well as failures of communications
between providers (failure to communicate patients condition or to
review medical record). The contributing factors were coded by clinical
taxonomy specialists who are registered nurses overseen by a taxonomy
governance committee of physicians, attorneys and other risk man-
agement specialists who oversee the coding process. The committee
provides regular audits to ensure consistency and accuracy of the coded
contributing factors and maintains a proprietary taxonomy manual
developed by CRICO. The coding process occurred prior to this study.
Additionally, the study authors (ABS, EYB, RDU) reviewed each of the
included case summaries and were provided the opportunity to clarify
any questions about contributing factors coding directly with staff from
CRICO.
Means and standard deviation as well as median and interquartile
range were reported for payments because they were not normally
distributed. Proportions were compared using Fisher's exact test. All
statistical analysis employed JMP pro 12 for Macintosh (SAS
Corporation, Cary, North Carolina, USA) with P < 0.05 as the criterion
for statistical significance and two-tailed tests.
3. Results
During the study period there were 2891 closed claims in which
anesthesiology was the primary responsible service. Among these there
were 58 claims (2.0%) involving anesthesia providers in the gastro-
intestinal endoscopy suite. Of the 58 claims, there were 8 (14%) colo-
noscopies, 8 (14%) cases with combined esophagogastroduodenoscopy
(EGD) and colonoscopy, 28 (48%) EGD, 11 (19%) endoscopic retro-
grade cholangiopancreatography (ERCP), and 3 (5%) endoscopic ul-
trasound (EUS), as shown in Table 2.
The total payment for all of the claims was $5,785,715. The mean
payment for all claims involving anesthesiologists in the endoscopy
suite was $99,754 (95% CI $11,547 to $187,956), with a median of $0
(IQR 0–$1486). When restricted to the 22 claims that resulted in pay-
ment (37.9% of cases), the mean payment rose to $275,510 (95% CI
$39,034 to $511,976) with a median payment of $7170 (IQR $1445-
$500,000). Other patient characteristics are listed in Table 2.
3.1. Outcomes
There was no significant difference in the percent of cases that re-
sulted in payment between the high, middle and lower severity cases
(31.3%, 40.9% 35.0% respectively, P = 0.83). However, there was a
significant difference in the percent of cases that resulted in payment
based on the procedure type, with 91% of ERCP cases resulting in
payment compared with 37.5% of colonoscopy cases, 25% of combined
EGD/colonoscopy cases, 21.4% of EGD cases and 0.0% of EUS cases
(P = 0.0008). ERCP cases contributed the largest percent of the total
A.B. Stone et al. Journal of Clinical Anesthesia 48 (2018) 15–20

Table 2
Patient demographics. * for two cases there were no reported age or gender and so
the denominator for the calculation of the mean patient age and percent male patient
was n = 56. **for median payment, only settled cases with payouts (n = 21) were
used for this calculation. SD = standard deviation, IQR = interquartile
range, EGD = esophagogastroduodenoscopy, ERCP = Endoscopic Retrograde
Cholangiopancreatography, EUS = Endoscopic ultrasound.
Case total (n) 58
Mean age (SD) 57.5 (12.9)
Male patient * 19 (33.9%)
High severity outcome 16 (27.6%)
Medium severity outcome 26 (44.8%)
Low severity outcome 16 (27.6%)
Settled cases (claims paid) 21 (36.2%)
Mean total payment (SD) $99,754 ($335,458)
95% confidence interval payment $11,547–$187,956
Median payment** (IQR) $7170 ($1445–$500,000)

Procedures
EGD 28 (48.3%)
ERCP 11 (19.0%)
EGD and colonoscopy 8 (13.8%)
Fig. 2. The percent of the total number of gastrointestinal endoscopy claims
Colonoscopy 8 (13.8%)
naming anesthesia provider as well as the percent of total indemnity that was
EUS 3 (5.2%)
paid to cover the claims. Low Severity events are defined as NAIC score be-
tween 0 and 2, Medium severity events include scores of 3–5 and High severity
events include scores of 6–9.

cases, the initial plan was to undergo the procedure without an en-
dotracheal tube.

3.2. Dental injury

There were 27 incidents of dental injury (46.6% of the total number

of cases). Dental injuries made up 80% of the low severity incidents (16
of 20) and 50% of the medium severity events (11 of 22). Of note, in
nine of the cases regarding dental injury, anesthesia was administered
without an endotracheal tube. A review of these cases demonstrates
that a common argument made by the plaintiffs was that the sedation
was inadequate causing the patient to bite down on the bite block and
injure his or her teeth.

3.3. Contributing factors

As mentioned previously, the CBS database uses a proprietary tax-

Fig. 1. Percent of the total number of gastrointestinal endoscopy-related claims
against anesthesia provider (n = 58) in the CBS database classified by the type
of the procedure. Percent of the total payment by each procedure type is also
shown.
indemnity paid (Fig. 1).
There were no significant differences in the mean NAIC severity
score between the types of procedures (P = 0.61). There were no sig-
nificant differences in the mean patient age between the types of pro-
cedures (p = 0.94).
There were 16 (27.5%) high severity events and 11 (19.0%) deaths
captured within the dataset. These events accounted for $4,525,000, or
78.2% of the total indemnity paid (Fig. 2). Two of these events were for
colonoscopies, two were for combined upper endoscopy and colono-
scopy procedures, four were for ERCPs and the remaining eight were
upper endoscopies. Propofol was mentioned explicitly in the case de-
scription of 50% of these severe events but was not implicated as a
direct cause of any of the adverse events. Fourteen of the sixteen severe
adverse events involved problems with oxygenation and ventilation.
The remaining two involved acute clinical status changes and hypo-
tension and failure to adequately resuscitate the patient (Table 3). The
patients had multiple co-morbidities; the most frequent of these was
obesity in five of the sixteen cases. In fifteen of the sixteen high severity
onomy to code contributing factors for the claims within the database,
as outlined in the Methods section. According to this coding framework,
the most common contributing factor for these adverse events was
technical skill (62.1%), followed by clinical judgment (48.3%), com-
munication (22.4%), and documentation (22.4%) (Table 1). Within the
technical skill category, the most common contributing factor men-
tioned was a possible technical problem from a known complication,
which was coded in 47% of the total cases, however these cases re-
presented 12% of the total payments. Another contributing factor in the
technical skill category, poor technique and failure to resuscitate, ac-
counted for 4% of the total cases, but the cases with this contributing
factor represented 41% of the total payments made. Within the clinical
judgment category, failure to monitor the physiologic status of the
patient was the most common subcategory coded in 16% of the cases.
These cases made up 65% of the total payment made. Upon manual
review by the authors of the available clinical summaries for the most
severe events (NAIC scores 6 or greater), 62.5% of these cases (10 of 16)
could have had oversedation as a possible contributing factor. For the
purposes of this study, oversedation was defined as unexpected changes
in the physiologic state of the patient and/or unplanned intubation for a
patient undergoing monitored anesthesia care. A third reviewer arbi-
trated any discrepancies in the classification of oversedation for a given
case. Additionally, obesity was identified as a possible contributing
factor in 6 of the 16 (37.5%) high severity cases (Table 1).

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A.B. Stone et al. Journal of Clinical Anesthesia 48 (2018) 15–20

Table 3
A brief description of severe adverse events in patients with specific comorbidities.
CAD = Coronary artery disease. COPD = chronic obstructive pulmonary disease. CHF = congestive heart failure. DM = diabetes mellitus. ESRD = end stage renal
disease; CPR = cardiopulmonary resuscitation; CO2 = carbon dioxide.
# Brief description Comorbidity(s)

Colonoscopy
1 Hypoxia and bradycardia without adequate airway protection CHF/COPD/obesity/cancer/DM
2 Difficult airway and attempted intubation due to clinical change during procedure. Tension pneumothorax None mentioned
Combined colonoscopy and upper endoscopy
1 Hypoxia with delayed recognition in prone position Obesity/DM
2 Difficult airway and hypoxia during procedure Obesity/COPD
Upper endoscopy
1 Acute respiratory failure and pneumonia following extubation ESRD/CHF/COPD/obesity
2 Hypoxia leading to bradycardia during procedure needing CPR ESRD/CHF/COPD
3 Hypoxia and hypoventilation (no end tidal CO2 monitoring) Obesity
4 Bradycardia and hypotension following procedure Alcohol abuse
5 Bradycardia and hypotension during procedure None mentioned
6 Hypoxia post-procedure and undocumented aspiration on intubation None mentioned
7 Respiratory failure following procedure requiring emergent intubation Cardiomyopathy
8 Airway edema and failure to secure airway Alcohol abuse
Endoscopic retrograde cholangiopancreatography
1 Hypoxia and bradycardia without adequate airway protection with patient in prone position CAD
2 Hypoxia and poor airway control and hypotension in setting of sepsis (cholangitis) Sepsis/obesity
3 Hypoxia leading to bradycardia, needing intubation with patient in prone position None mentioned
4 Hypoventilation and failure to recognize drop in end-tidal CO2 COPD/smoker/previous Roux en Y

4. Discussion 4.2. ERCP

In this study, we examined closed claims obtained from the CRICO
CBS database involving anesthesia providers in the gastrointestinal
endoscopy suite. Our data suggest that the majority of indemnity pay-
ments come from high severity events. Excluding dental injury, the
most common claims against anesthesiologists involve serious events
and patient deaths, which were most commonly caused by respiratory
compromise. The most commonly cited contributing factor was failures
related to technical skill. ERCP cases were over-represented in the
subset of claims that resulted in payment. Similar to other NORA lo-
cations, challenges in the endoscopy suite include anesthetizing loca-
tions located far away from the main ORs, fewer staff and material
recourses, suboptimal lighting, and unfamiliar equipment [13]. Pre-
vious studies have shown that rate of complications is lower in the
gastrointestinal endoscopy suite when compared with the interven-
tional radiology suite and cardiac catheterization laboratory [4,14].
This may be secondary to a larger number of screening procedures in
healthier individuals [4,14].
4.1. Dental injuries
Our study shows that dental injuries remain a frequent cause of
claims in the gastroenterology suite. Dental injuries were excluded from
prior closed claims analyses [4,8,14]. Surprisingly, a significant portion
of these occurred in procedures done with a natural airway. Anesthe-
siologists were named in lawsuits as being responsible for injuries
caused by patients biting on the endoscope. The severity of the dental
injuries ranged from chipped teeth to dentures being dislodged and
eventually recovered from the GI tract. Dental injuries occurred in each
type of procedure (EGD, ERCP, colonoscopy). Our data suggest that
even in cases with planned natural airways, it is critical to complete and
document a dental examination and include the risk of dental injury in
the informed consent process. Our analysis also suggests that the ab-
sence of an endotracheal tube, or an anesthesiologist-performed lar-
yngoscopy does not absolve the anesthesia team from the responsibility
for dental injuries, and we recommend that anesthesia providers discuss
these risks with patients even if a natural airway is planned.
Within the CBS database, ERCP cases had a much higher likelihood
of a claim resulting in payment. Interestingly, ERCPs did not have a
higher average severity score in terms of outcomes or a greater average
patient age. While we cannot say definitively, these data suggest that
there is something unique to ERCPs that increases the liability of an-
esthesiologists for this procedure.
In order to cannulate the common bile duct, ERCPs may be per-
ceived to require a deeper level of sedation. Previous studies have
shown that in non-intubated patients, the rates of unintentional deep
sedation were higher for ERCP than EGD or colonoscopy [15]. An ad-
ditional contributing factor could be related to the prone positioning of
the patient for ERCPs. The decision to position the patient in either the
prone or lateral decubitus position often falls to the gastroenterologist.
Some data suggest that both positions are safe for healthy patients.
However, prone positioning is preferred by many proceduralists
[16,17]. Based on our data, prone positioning was a factor in all four
high severity ERCP cases. In two of these cases, the positioning con-
tributed to less frequent monitoring of end-tidal CO2 and likely led to
delays in recognizing an acute clinical change. In two other cases, when
providing manual ventilation of the patient became necessary, prone
positioning made it more difficult. Previous analysis of the ACCP
showed a connection between prone positioning and adverse re-
spiratory outcomes in patients undergoing monitored anesthesia care
for an ERCP [18].
The four high severity ERCP cases were started with a natural
airway and monitored anesthesia care, but were eventually converted
to general endotracheal anesthesia. Three out of four of these cases
were described as having a difficult airway. There is currently debate as
to which patients should be intubated prior to ERCP [19]. The risks of
hypoxemia, aspiration, inadequate monitoring with a natural airway
must be weighed against the risks of intubation, paralytics, and reduced
efficiency that comes with routinely intubating patients. A retrospective
study at a high volume academic center showed that healthy patients
could safely receive monitored anesthesia care for ERCPs rather than
general anesthesia with intubation, whereas a significant proportion of
obese patients were converted to a general anesthetic with an artificial
airway [20]. Ultimately, more studies and randomized controlled trials

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A.B. Stone et al.
are needed to determine which patients should and should not be in-
tubated for ERCPs. Our data, selected from a closed claims database, is
biased towards the most severe complications. Had these patients been
intubated from the outset, it is possible that the adverse outcomes could
have been avoided. Still, adequate pre-procedural screening for ERCPs
may have also prevented some of the most severe outcomes by pro-
viding more data to determine if the patient, based on his or her
medical condition and procedure requirements would benefit from in-
tubation for the ERCP. Also, in the cases reviewed, better preoperative
screening may have been able to detect which patients would have a
difficult airway.
4.3. EGD
There were eight high severity adverse events for patients under-
going EGD. In four of the eight cases, the patients were admitted to the
hospital and underwent an EGD for evaluation of a gastrointestinal
bleed. In six of the eight procedures, there was an apparent delay be-
tween the Certified Registered Nurse Anesthetist (CRNA) calling for
help and the supervising physician anesthesiologist arriving. In two
cases, there were discrepancies in the documentation between the
gastroenterologist and the anesthesiologist. All of the upper endoscopy
cases involved airway management and/or respiratory compromise.
Interestingly, none of these severe EGD cases resulted in payment, and
all of the cases were eventually either dismissed or dropped.
These data suggest that while airway compromise is a risk in EGD,
the anesthesia providers are able to recognize quickly these changes
and act accordingly.
4.4. Colonoscopy
There were only two high severity events associated with colono-
scopy procedures. Both of these events were respiratory and cardio-
vascular collapse that occurred during a screening colonoscopy in the
endoscopy suite. In one case, the anesthesiologist was located on an-
other floor while the CRNA was administering anesthesia to the patient,
delaying the response to the patient's condition. In the other case, the
patient was having a routine colonoscopy done at an outpatient clinic.
The patient was oversedated with midazolam. When the proceduralist
asked for flumazenil, the CRNA instead gave glycopyrrolate. The pro-
cedure was aborted and the patient was transferred to the emergency
department. The airway was not secured prior to transport. During
transport, the patient suffered hemodynamic collapse and was unable to
be resuscitated.
Both of the colonoscopy cases with a high severity outcome in-
volved a failure to adequately manage the patient following an acute
clinical change during a routine screening procedure. Having more
resources available, such as the supervising physician anesthesiologist
nearby, may have affected the outcome in both of those cases.
4.5. High severity events
Our dataset included 16 high severity events that resulted in per-
manent damage or death. In 94% of the cases with a severe adverse
event, the initial plan was to do the procedure with monitored an-
esthesia care. Most of the cases involved hypoventilation and hypoxia
during the procedure, and there were multiple cases of failure to re-
suscitate the patient following an acute clinical change. There were six
cases with payments of $500,000 or more. In each of these cases, the
rationale for the payment was that the patients were mismanaged and
not adequately rescued once the patient's clinical status changed. In all
of the six cases with large payments, the patients had difficult airways
and one patient required a cricothyroidotomy. Inconsistent doc-
umentation was cited as a factor in two of these cases. While over-
sedation may have played a role, it was not mentioned in any of the
case summaries as the primary reason for why the case resulted in
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Journal of Clinical Anesthesia 48 (2018) 15–20
payment. Rather, according to the CRICO-coded contributing factors, it
was the failure of the anesthesia provider to recognize the clinical
physiologic changes, which was the most common cause in the cases
that resulted in a payment.
Failure in technical skills (e.g. poor technique and failure to manage
a known possible complication) was the most common contributing
factor, contributing in over half of the cases per the CRICO coders.
However, the majority of these cases did not result in payment and
were also coded as known possible complications. The cases that were
coded as a failure to resuscitate the patient adequately were correlated
with a large percent of the total payment. These data suggest that well
trained and equipped personnel that are able to resuscitate the patient
who is experiencing clinical deterioration can reduce liability to an-
esthesia providers in the endoscopy suite.
4.6. Oversedation
Prior analysis of the ACCP database focused on oversedation as a
key driver for adverse events in the endoscopy suite [8] and more
studies have focused on oversedation as possible causes of harm to
patients [9,21,22]. A recent large retrospective analysis of over a mil-
lion cases from a national gastroenterology database reported that an-
esthesiologist-directed sedation was actually a risk factor for serious
adverse events with upper endoscopy and that there was no difference
with lower endoscopy [10]. In that same analysis, half of the cases were
thought to be preventable with better monitoring. These data from the
gastroenterology literature have been used to argue against having
anesthesiologists provide services for at least some endoscopy cases.
Our analysis showed that oversedation was a contributing factor in the
majority of high severity adverse events. A previous ASA closed claims
analysis of all monitored anesthesia cases found that 24% of the over-
sedation cases were for endoscopic procedures [18]. In that same
analysis, half of the cases were thought to have been able to be pre-
ventable with better monitoring [18]. However, while oversedation
may have played a role, it was the related contributing factors such as
the inability to recognize and react to the evolving situation, and the
failure to resuscitate and/or maintain adequate ventilation and oxy-
genation, which allowed for harm to transpire. When the anesthesia
provider was able to promptly respond to clinical changes, there was
less liability and fewer settlements as shown in EGD cases in our ana-
lysis. When there were delays in response, the anesthesia providers
were more likely to be liable and the case resulted in payment as de-
monstrated by the ERCP cases in our study. The available data did not
allow for us to determine whether or not oversedation was preventable
for each of the cases.
4.7. Risk factors
Using the available data, we observed that obesity was judged to be
a contributing factor in six of the cases with severe adverse events.
Obesity is a well described risk factor leading to adverse events during
operating room anesthesia [22,23]. The rising rates of obesity in the
population as well the emerging field of bariatric endoscopy [24] en-
sure that the number of obese patients undergoing gastrointestinal
endoscopy will likely rise in the near future. Further studies are needed
to identify patients at higher risk for adverse events during endoscopy.
One of the limitations of this study is that not all patient co-morbidities
could be abstracted in the claims data available to us for review.
4.8. Limitations
This study, like other closed claims analyses has several limitations
[25]. The CBS database captures only a partial numerator, because not
all complications result in a malpractice insurance claim. It is im-
possible, based on the data presented, to estimate a denominator and
comment on the incidence of complications for providing anesthesia for
A.B. Stone et al.
gastrointestinal endoscopy. By virtue of examining malpractice in-
surance claims, the data presented are biased towards more severe
outcomes. Furthermore, this is a retrospective analysis without a clear
control group, and so clear causation cannot be established. These data
are not randomized and may be subject to regional biases as well. The
coded data are also proprietary to CRICO and are therefore unable to be
verified by an outside entity. The cases were originally analyzed by
trained registered nurses at CRICO rather than anesthesiologists, and
therefore the study lacks independent reliability assessments by board-
certified anesthesiologists who were practicing at the time. However,
the authors (A.B.S, E.Y.B., R.D.U.) reviewed all case summaries in-
cluded in this study. The data collected for the CBS database were
originally intended for medicolegal purposes limiting the number and
type of the clinical endpoints that were collected and analyzed [26]. In
addition, our conclusions should be interpreted with the acknowl-
edgement that in malpractice litigation, it is possible to have a financial
award even in the absence of negligent care [27] as well as substandard
care that does not result in a financial settlement [28].
5. Conclusion
This is the first study to conduct a detailed medicolegal analysis of
malpractice cases that involved anesthesia providers specifically in the
gastrointestinal endoscopy suite. Our data suggest that there are dif-
ferences in the rate of malpractice payments by gastrointestinal pro-
cedure type. Our analysis also suggests that oversedation alone gen-
erally does not lead to medicolegal liability for anesthesia providers
practicing in the endoscopy suite. Rather, it is the allegations of tech-
nical and clinical judgment failures, such as the inability recognize
acute clinical deterioration or manage difficult airways that result in
medicolegal settlements in the cases that we reviewed. Our closed claim
analysis suggests that even when adverse events do occur in the en-
doscopy suite, anesthesiologists are less likely to be found liable when
highly trained and well equipped providers are readily available.
Individual contributions
A.B.S, E.Y.B. and R.D.U. conceived this study. A.B.S. E.Y.B., and
R.D.U. designed and performed the data analysis. A.B.S., E.Y.B., P.G.
and R.D.U. participated in the interpretation of the data. A.B.S. and
R.D.U. drafted the initial manuscript. E.Y.B., P.G. and R.D.U. provided
critical revision of the manuscript.
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