Criminalizing anesthesia errors has unintended consequences, experts warn

Editor's Note

Treating unintended anesthesia errors as criminal acts could exacerbate workforce shortages, increase malpractice costs, and drive clinicians to defensive medicine, according to experts quoted in a January 15 report from Anesthesiology News. Instead, fostering a culture of safety and learning could more effectively reduce errors and improve patient outcomes.

The article focuses on a presentation from the Anesthesia Patient Safety Foundation’s (APSF) 2024 Stoelting Conference, where APSF President Steven Greenberg, MD, detailed the persistent challenge of medication errors in anesthesia, which occur in about 1 in every 20 anesthetic administrations. Substitution errors—administering the wrong drug in place of another—are the most common examples. Criminalizing these mistakes, Greenburg continued, can discourage reporting and learning from errors, and the APSF is working to educate prosecutors and reassure clinicians.

According to the article, Greenberg distinguished between unintentional errors and cases where healthcare professionals deliberately cause harm, noting that the latter should be prosecuted. Reckless behavior or errors occurring under the influence of drugs or alcohol may also warrant legal action. However, the focus should be on system-wide safeguards, such as heightened awareness of look-alike medications and fostering a culture where staff feel empowered to report risks. “We only should use override methods for urgent and emergent clinical circumstances; and when we do that, we should institute a double verification system,” he said.

As detailed in the article, a separate case study presented at the conference illustrated how a medication error led to systemic changes. Attorney Paul Lefebvre described an incident where an anesthesiologist mistakenly administered tranexamic acid (TXA) instead of mepivacaine during a neuraxial block, causing a patient to experience seizures and requiring a four-day medically induced coma. The error resulted from look-alike vials, new vendor-supplied medications, and poor storage practices. Following the incident, the practice group implemented double-check protocols for local anesthetics and restructured TXA storage, opting for prefilled infusion bags to prevent similar mistakes. Lefebvre underscored the importance of reporting near-miss events and viewing errors as opportunities for improvement rather than punishment.