Anaesthesiological risk assessment and anesthesia-related medical errors: analysis of commission forensic examinations

Objective. To study the relationship between defects in anesthetic care and ASA anesthetic risk assessment considering material of commission forensic examinations. Material and methods. We examined 4643 archival reports of commission forensic medical examinations (FME) at the St. Petersburg Bureau of Forensic Medical Examination between 2014 and 2018. Anesthesiologists and intensive care specialists were involved as members of expert commissions in 425 cases. In 29 cases, they found a direct cause-and-effect relationship between intensive care defects and mortality. The causes and conditions contributing to such unfavorable outcomes were studied in detail. Results. The most common were defects in organization of medical care (insufficient provision or absence of necessary therapeutic and diagnostic means) — 14 (48%) cases. Treatment defects were less common (prescription and implementation of drug therapy, medical procedures) — 11 (38%) cases. At the same time, diagnostic defects (other complications and concomitant diseases were not recognized, i.e. there was underestimation of baseline somatic status and risk) occurred only in 4 (14%) cases. Anesthetic risk in 26 elective and 3 emergency patients who died from to intensive care defects corresponded to ASA grade I—III. Conclusion. Analysis of commission forensic examinations indicates that the causes of most deaths related to anesthesia lie outside the assessment of physical status and surgery. Thus, the routine risk assessment approach does not consider all actual risk factors (lack of necessary equipment, drugs, personnel qualifications, etc.). As a result, intensive care defects come to attention of forensic medical commission, mainly in unburdened patients.