Failure to Recognize Loss of Incoming Data in an Anesthesia Record-Keeping System May Have Increased Medical Liability

Abstract

In Brief Automated anesthesia record-keeping systems (AARKs) are increasingly being used. There is a perception that AARKs may limit medical liability. We report a case in which our AARK may have increased our medical liability exposure. Nine months after a patient suffered a serious intraoperative complication, the anesthesiologist was named (as one of several defendants) in a claim alleging failure to properly monitor anesthetic care. One reason why the anesthesiologist was named related to a gap of 93 min in which no vital signs were documented in the anesthesia record. Relying on the physiological monitors to assess the patient's condition, the anesthesiologist did not recognize the interruption of data transmission, because the “active” medication window obscured the graphical display of the vital sign window. IMPLICATIONS: We report an unrecognized data transmission loss while using an automated anesthesia record keeping system. A documentation window concealed the home screen window, which displayed graphical vital sign data. Absence of vital signs on the printed anesthesia record, and a bad surgical outcome, increased our medical liability exposure.

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