The DOI matches its Crossref record; 3 of the 3 references it cites were found in a registry or an index.
Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Analysis
Open accessAbstract
BACKGROUND: Situational awareness errors may play an important role in the genesis of patient harm. The authors examined closed anesthesia malpractice claims for death or brain damage to determine the frequency and type of situational awareness errors. METHODS: Surgical and procedural anesthesia death and brain damage claims in the Anesthesia Closed Claims Project database were analyzed. Situational awareness error was defined as failure to perceive relevant clinical information, failure to comprehend the meaning of available information, or failure to project, anticipate, or plan. Patient and case characteristics, primary damaging events, and anesthesia payments in claims with situational awareness errors were compared to other death and brain damage claims from 2002 to 2013. RESULTS: Anesthesiologist situational awareness errors contributed to death or brain damage in 198 of 266 claims (74%). Respiratory system damaging events were more common in claims with situational awareness errors (56%) than other claims (21%, P < 0.001). The most common specific respiratory events in error claims were inadequate oxygenation or ventilation (24%), difficult intubation (11%), and aspiration (10%). Payments were made in 85% of situational awareness error claims compared to 46% in other claims (P = 0.001), with no significant difference in payment size. Among 198 claims with anesthesia situational awareness error, perception errors were most common (42%), whereas comprehension errors (29%) and projection errors (29%) were relatively less common. CONCLUSIONS: Situational awareness error definitions were operationalized for reliable application to real-world anesthesia cases. Situational awareness errors may have contributed to catastrophic outcomes in three quarters of recent anesthesia malpractice claims.Situational awareness errors resulting in death or brain damage remain prevalent causes of malpractice claims in the 21st century.
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“Lapses in SA are a primary cause of safety-related incidents and accidents [13, 14].”
From Use of artificial intelligence in critical care: opportunities and obstacles (2024) · cites this paper as [14]
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“The rapid advances in AI, and in particular the release of publicly available generative AI applications leveraging advanced large language models, have greatly accelerated discussions considering the promises and pitfalls related to AI deployment in society and healthcare [7–17].”
From Use of artificial intelligence in critical care: opportunities and obstacles (2024) · cites this paper as [14]
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Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009) · Journal of Biomedical Informatics · doi:10.1016/j.jbi.2008.08.010 · Cited by 51,384
A surgical safety checklist to reduce morbidity and mortality in a global population
Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A.-H. S., Dellinger, E. P., Herbosa, T., Joseph, S., Kibatala, P. L., Lapitan, M. C. M., et al. (2009) · New England Journal of Medicine · doi:10.1056/nejmsa0810119 · Cited by 5,688
Situation Awareness in Anesthesia: Concept and Research
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Cited by
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Said, S., Gozdzik, M., Roche, T. R., Braun, J., Rössler, J., Kaserer, A., Spahn, D. R., Nöthiger, C. B., & Tscholl, D. W. (2020) · Journal of Medical Internet Research · doi:10.2196/19472 · Cited by 173
Use of artificial intelligence in critical care: opportunities and obstacles
Pinsky, M. R., Bedoya, A., Bihorac, A., Celi, L., Churpek, M., Economou-Zavlanos, N. J., Elbers, P., Saria, S., Liu, V., Lyons, P. G., et al. (2024) · Critical Care · doi:10.1186/s13054-024-04860-z · Cited by 160
“Lapses in SA are a primary cause of safety-related incidents and accidents [13, 14].”
Background
Metadata
- Authors
- Schulz, C. M., Burden, A., Posner, K. L., Mincer, S. L., Steadman, R., Wagner, K. J., & Domino, K. B.
- Affiliations
- University of Washington (US)
- Corresponding author
- Schulz, Christian M.
- Venue
- Anesthesiology
- Published
- 2017-08
- Volume
- 127
- Issue
- 2
- Pages
- 326-337
- ISSN
- 0003-3022 (ISSN-L)
- PMC
- PMC6237430
- OpenAlex
- W2608681048
- Cited by
- 113
- References
- 3
- Citations by year
- 2026: 5 · 2025: 17 · 2024: 12 · 2023: 14 · 2022: 11 · 2021: 18 · 2020: 15 · 2019: 15 · 2018: 6
- FWCI
- 16.91
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Anesthesiology (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- mediaTUM – the media and publications repository of the Technical University Munich (Technical University Munich) (submittedVersion)
- Funders
- National Institutes of Health (UL1TR002319)
- National Center for Research Resources (UL1RR025014)
- National Center for Advancing Translational Sciences
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
- Social Sciences › Law › Medical Malpractice and Liability Issues
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Keywords
- patient death, brain damage, anesthesia errors, perceptual errors, comprehension errors, projection error, respiratory system damage, difficult intubation, aspiration
- MeSH terms
- Anesthesia, Awareness, Brain Injuries, Clinical Competence, Female, Humans, Insurance Claim Review, Male, Malpractice, Middle Aged, Databases, Factual
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