Educate certified registered nurse anesthetists (CRNAs) about their unique malpractice risks. Their elevated education provides autonomy that can make them likely targets of litigation.

• Maintaining competency and skills is a top priority.

• Lax documentation is at the root of many CRNA lawsuits.

• Communication about the patient’s condition can be another weak point with CRNAs.

Certified registered nurse anesthetists (CRNAs) face liability risks unique to their profession, and risk managers can assist them by reminding them of the potential pitfalls in their work and the best ways to minimize their exposure.

CRNAs are among the most vulnerable in the nursing profession because their high skill level affords them greater autonomy, notes Georgia Reiner, risk specialist for the Nurses Service Organization (NSO) in the Healthcare Division of Aon Affinity Insurance Services in Philadelphia. With that autonomy comes greater responsibility for adverse outcomes and potential liability.

The NSO recently highlighted a case study of a CRNA who performed a peribulbar eye block on an ambulatory surgery patient prior to his cataract surgery. After an adverse outcome, the CRNA was the only clinician sued. When the patient refused to settle for less than $500,000, the matter went to trial. Even though the trial ended with a defense verdict, the estimated legal fees after three years were $270,000. (For more on that case and the risk management implications, see the case study online at: https://bit.ly/2GfvdeQ.)

“Risk management’s role is to be the informer, helping to improve patient safety and minimize exposure by providing information on the patterns and trends and losses we see,” Reiner says. “We hope that risk managers can use the information from NSO to help evaluate the risk exposures that they have identified in their organizations and implement changes that will lead to better outcomes for their patients and reduce liability for the organization, as well.”

Reiner suggests educating CRNAs on the following strategies for avoiding liability:

• Stay on top of staff experience, training, and skills, monitoring for continuing education.

Policies and procedures should be in place to regularly assess the education and training needs of staff, and evaluate each professional’s credentials and competencies, she says.

“It behooves the CRNAs themselves to maintain their education and skills, but it also behooves the organization to support that process by having policies and procedures in place that assess the education and training of their staff to evaluate where any gaps may exist,” Reiner says. “It is important for organizations to support that process because when you have a well-educated, skilled workforce, everyone benefits.”

• Document informed consent for every procedure involving anesthesia.

CRNAs should verify that informed consent was obtained and documented in the patient’s health record. Risk managers should confirm that verification of this informed consent process is part of any checklist or time-out procedure completed before an anesthetic intervention.

“It’s important to look at policies and procedures and make sure they support any work the healthcare provider is doing with patients, so obtaining feedback from providers about potential gaps is important,” she says.

“If you don’t seek that feedback, it is possible that you have conflicts or shortcomings with your policies and procedures that CRNAs know about — and you could correct if you ask them.”

• Note any pertinent anesthesia-related information on the patient’s record, including allergies.

Risk managers can work with clinical directors and health information management to ensure that pertinent information can be effectively recorded in the patient’s health record and appropriate alerts are in place to notify practitioners of any urgent concerns, such as allergies or potentially adverse drug interactions.

“We know that some of the top allegations made against CRNAs in malpractice lawsuits involve improper treatment or intervention, or inadequacies in the anesthesia plan,” Reiner says. “We have identified that documentation can be lacking, and when it is, that makes defense of the CRNA much more difficult.”

• Continually monitor the patient’s status and response to treatment, and report changes in a timely manner.

“Sometimes we see a failure to provide and document to the practitioner a change in the patient’s status,” Reiner says. “That breakdown in communications can lead to adverse outcomes for the patient.”

• Document practitioner notification of status changes.

CRNAs must report changes in the patient’s condition, any new symptoms, or any patient concerns to the practitioner in charge of the patient’s care, Reiner says. CRNAs also should document the practitioner’s response and any orders in the patient’s health record.

“Risk managers and organizational leadership should work together to identify barriers to effective team functionality and design systems that help foster collaborative, patient-centered healthcare teams and improve communication among healthcare professionals,” Reiner says.

“To that end, risk management programs should include an educational component to help engage staff in improving the quality and safety of care at their organization.”

Patient safety initiatives and educational programs such as Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) and Quality and Safety Education for Nurses (QSEN) can improve communication and teamwork among healthcare professionals, and between providers and patients, Reiner suggests.

• Report any patient incident, injury, or adverse outcome.

Rather than blaming individuals when errors or near-misses occur, risk managers should promote shared accountability and engage healthcare providers in the process of understanding the causes of errors. Risk managers must encourage CRNAs and other healthcare providers to report any patient injury or adverse incidents, as it is only through the incident reporting and root cause analysis process that patient care and treatment practices can improve, Reiner says.

“Risk managers should also encourage CRNAs to alert their professional liability carrier to any potential claims, as timely reporting ensures that an incident, if it develops into a covered claim and is not excluded for other reasons, will be covered,” Reiner says. “Rather than focusing on blaming individuals for any particular error or liability, risk managers should promote shared accountability to understand the root causes of errors. To foster that environment, risk managers should encourage CRNAs to report any near misses or adverse outcomes without fear of retribution.”


• Georgia Reiner, Risk Specialist, Nurses Service Organization, Healthcare Division, Aon Affinity Insurance Services, Philadelphia. Email: georgia.reiner@aon.com.