LIFE-CHANGING Going through a malpractice suit has caused many clinicians to consider careers outside of medicine.

A majority of anesthesia providers will face a lawsuit during their careers, but most claims are preventable. As I often remind our younger staffers, don't step beyond the boundaries of good sense. Adhering to these 5 rules of thumb is a good place to start.

1Stay true to the basics. Most anesthesia-related malpractice cases probably could have been avoided by adhering to the basic principles. For example, never using supplemental oxygen near an ignition source, as we saw in the case of an elderly patient's face igniting at an Oregon surgery center (osmag.net/E7zrNR). It's often production pressure that causes errors. Some facilities are all too willing to take shortcuts: not taking time outs or letting the surgeon steamroll you because you're afraid to make him wait until it's safe to proceed. In anesthesiology, speed kills. Unless there's a situation involving loss of airway or arterial bleeding, slow it down.

2Don't normalize deviant behavior. A facility's profitability depends on its ability to maintain a strong case volume. That's all well and good — until a dollar amount is placed above patient safety. If a patient comes in with a BMI of 55 who's clearly not appropriate for an outpatient setting and you say, "Okay, let's do this," you may be putting the patient, the facility and yourself in jeopardy.

Most ambulatory facilities will not take patients with a BMI above 40, which I think is the safest approach. Some have gone as high as 50, which is on the razor's edge. Someone with a BMI of 55 might have a perfectly fine airway, but they still have a BMI of 55 and all the potential complications that come with it.

3Build relationships based on mutual respect. Some surgeons will adopt the attitude of, "This is my patient," and they believe that whatever they say goes. But as an anesthesia provider, it's your patient, too, and you have a duty and a responsibility to that patient. You must have the confidence to know the difference between keeping the peace with an overeager surgeon and veering into territory that could endanger the patient. After all, if there's an injury, and your action or inaction is determined to be the proximate cause, it's your license on the line.

4Stay away from "cowboys." Safety starts with having the right people on your team. If you need to staff a case with an anesthesia provider, don't just take the first body that comes in the door. Avoid anyone who is cavalier about the way they practice — "cowboys," as I call them. They're overconfident, even cocky, and they're the ones who scare me the most.

We have a very strict code about patients: Treat everyone as if she is your mother. If you do that from the very beginning, it keeps you honest and it prevents you from stepping into territory where you shouldn't be. I don't want anyone in the OR who doesn't share that mentality. Make sure you have a robust vetting process. Anesthesia is a small community, so it's easy to make a phone call and find out if a provider would be a good fit for your team.

5Document everything. In the event that something goes south during a case, you'll need to make a few phone calls immediately — to the facility manager or risk representative, for starters. You'll also want to go back and make sure the patient's chart is in order. You can't make changes to the chart, but if you were too busy caring for the patient to chart during the case, you can make additions with a chronological list of progress notes. It doesn't have to include specific times, but it should contain the sequence of events as they unfolded. In these kinds of cases, juries want to see that you're taking care of the patient, and the progress notes will help to show that you acted responsibly.

When a lawsuit finally manifests itself, it might be years after the fact that you find yourself in a courtroom and someone hands you a chart, asking you to explain what happened. When that moment comes, the chart probably won't have all the information you'll need, and you don't want to go strictly by memory.

After an incident, go home that night and write down every possible detail about that day and about that case — what you did do, what you didn't do, even what you wish you had done. In a lawsuit scenario, a private letter to yourself is not discoverable, but you don't share it with anyone.

ANOTHER MALPRACTICE CASUALTY: YOUR TIME
The Wheels of Justice Turn Slowly

STEALING TIME The average physician involved in a malpractice claim spends more than 4 years with an unresolved claim.

The average physician involved in a malpractice claim spends 50.7 months — almost 11% of an assumed 40-year career — with an unresolved claim, according to a Health Affairs study of malpractice claims data for more than 40,900 physicians. The length of time of an outstanding malpractice case causes tremendous anxiety for the physician named in the suit, the study says.

Early disclosure and apologies from physicians may make patients less likely to pursue litigation, says Darrell Ranum, JD, CPHRM, vice president of patient safety for The Doctors Company, a physician-owned malpractice insurer based in Napa, Calif.

"Even if it reflects poorly on the physician, hospitals are now working with risk managers to help physicians share that kind of information in a delicate way," says Mr. Ranum. This includes being open with the patient about what happened, including if mistakes were made. "We think because physicians are having those conversations, some patients don't see the need to find a lawyer to get an answer for them," he says.

— Bill Donahue

What's at stake?
The losses incurred in a malpractice suit inevitably go much further than the monetary judgments against a defendant. Any clinician who has ever been named in one of these suits will likely say it affected them personally just as much as it did professionally. Nothing about a malpractice suit is pleasant. Being deposed, having to endure a trial, being put on the stand and having to explain how your actions led to a most unwanted outcome — these are the kinds of life-changing experiences that make people want to leave our profession. That's why we need to do everything in our power to make sure patients leave our ORs in better shape than when they came in. OSM