Closed Claims Publications & Presentations

Review Closed Claims Program publications and presentations by year below or request more information at ClosedClaims@asahq.org.

  • Hawkins J, Dutton RP. Closed Claims Case Review Case 2024-09: Diagnosis and Management of Subdural Catheters. ASA Monitor 88(9):p 14, September 2024. | DOI: 10.1097/01.ASM.0001050656.43883.b0

  • Black C, Domino KB. Blaze of Consequences: Preventing Laser-Fire Related Injuries in Airway Surgeries. 2024 ASA Anesthesiology Annual Meeting – ePoster Presentation.
  • Black C, Domino KB. Communication Crisis: Anoxic Brain Injury Resulting from Communication Breakdown. 2024 ASA Anesthesiology Annual Meeting – ePoster Presentation.
  • Black C, Domino KB. Post-op Pulmonary Edema: Fatal Consequence in Ambulatory Rotator Cuff Repair. 2024 ASA Anesthesiology Annual Meeting – ePoster Presentation.
  • Black C, Domino KB. Vasopressor Complications: From Gastric Bypass to Hand Amputation. 2024 ASA Anesthesiology Annual Meeting – ePoster Presentation.
  • Black C, Domino KB. When a Rotator Cuff Repair Encounters Heartbreak: Investigating Hypertension-Induced Takotsubo Cardiomyopathy. 2024 ASA Anesthesiology Annual Meeting – ePoster Presentation.

  • Saul SA, Ward PA, McNarry AF. Airway Management: The Current Role of Videolaryngoscopy. J Pers Med. 2023;13(9):1327. Published 2023 Aug 29. DOI:10.3390/jpm13091327
  • Lin DM. Closed Claims Case Review Case 2023-11: Unanticipated Outcome after Peripheral Nerve Block: Role for Communication and Consent. ASA Monitor 87(11):p 15-17, November 2023. | DOI: 10.1097/01.ASM.0000995072.64491.66
  • Kent C. Closed Claims Case Review Case 2023-8: Making Sense of Local Anesthetic Systemic Toxicity. ASA Monitor 87(8):p 33-34, August 2023. | DOI: 10.1097/01.ASM.0000949616.89467.de
  • Connolly L. Closed Claims Case Review Case 2023-05: A Little too Late – A Case from the Crypt. ASA Monitor 87(5):p 13, May 2023. | DOI: 10.1097/01.ASM.0000935268.43291.a6
  • Dutton RP. Closed Claims Case Review Case 2023-1: Anesthesia Management of Postpartum Hemorrhage. ASA Monitor 87(1):p 13, January 2023. | DOI: 10.1097/01.ASM.0000911732.97913.e2
Warner MA, Meyerhoff KL, Warner ME, Posner KL, Stephens L, Domino KB. Pulmonary Aspiration of Gastric Contents: A Closed Claims Analysis. Anesthesiology. 2021;135(2):284-291. DOI:10.1097/ALN.0000000000003831

Joffe AM, Aziz MF, Posner KL, Duggan LV, Mincer SL, Domino KB. Management of Difficult Tracheal Intubation: A Closed Claims Analysis. Anesthesiology. 2019;131(4):818-829. DOI:10.1097/ALN.0000000000002815

Publication Year Reference Details Access Link
2018 Chui J, Murkin JM, Posner KL, Domino KB. Perioperative Peripheral Nerve Injury After General Anesthesia: A Qualitative Systematic Review. Anesth Analg 2018;127:134-43. doi: 10.1213/ANE.0000000000003420 https://pubmed.ncbi.nlm.nih.gov/29787414/
2017 Honardar MR, Posner KL, Domino K.B. Delayed Detection of Esophageal Intubation in Anesthesia Malpractice Claims: Brief Report of a Case Series. Anesth Analg 2017;125(6):1948-51 https://www.ncbi.nlm.nih.gov/pubmed/28207593
2017 Kent CD, Stephens LS, Posner KL, Domino KB. What Adverse Events and Injuries Are Cited in Anesthesia Malpractice Claims for Nonspine Orthopaedic Surgery? Clin Orthop Relat Res 2017;doi:10.1007/s11999-017-5303-z https://www.ncbi.nlm.nih.gov/pubmed/28255948
2017 Kutteruf R, Wells D, Stephens L, Posner KL, Lee LA, Domino KB: Injury and Liability Associated With Spine Surgery. J Neurosurg Anesthesiol 2017; 30:156-62 https://www.ncbi.nlm.nih.gov/pubmed/28763433
2017 Prielipp RC, Weinkauf JL, Esser TM, Thomas BJ, Warner MA: Falls From the OR or Procedure Table. Anesth Analg 125:846-51, 2017 https://www.ncbi.nlm.nih.gov/pubmed/28598918
2017 Schultz CM, Burden A, Posner KL, Mincer SL, Steadman R, Wagner KJ, Domino KB. Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Analysis. Anesthesiology 2017; 127(2):326-37 https://www.ncbi.nlm.nih.gov/pubmed/28459735
2016 Fitzgibbon DR, Stephens LS, Posner KL, Michna E, Rathmell JP, Pollak KA, Domino KB. Injury and liability associated with implantable devices for chronic pain. Anesthesiology 124:1384-93, 2016 http://www.ncbi.nlm.nih.gov/pubmed/27054366
2015 Kent CD, Posner KL, Mashour GA, Mincer SL, Bruchas RR, Harvey AE, Domino KB. Patient perspectives on intraoperative awareness with explicit recall: report from a North American anaesthesia awareness registry. British Journal of Anaesthesia 2015 115 (suppl 1): i114-i121 doi: 10.1093/bja/aev211 http://www.ncbi.nlm.nih.gov/pubmed/26174296
2015 Lee, L.A., Caplan, R.A., Stephens, L.S., Posner, K.L., Terman, G.W., Voepel-Lewis, T., Domino, K.B.: Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology 122(3): 659-65, 2015. http://www.ncbi.nlm.nih.gov/pubmed/25536092
2015 Maxwell, B.G., Posner, K.L., Wong, J.K., Oakes, D.A., Kelly, N.E., Domino, K.B., Ramamoorthy, C.: Factors Contributing to Adverse Perioperative Events in Adults with Congenital Heart Disease: A structured analysis of cases from the Closed Claims Program. Congenit Heart Dis. 10:21-9, 2015 http://www.ncbi.nlm.nih.gov/pubmed/24869762
2015 Pollack KA, Stephens LS, Posner KL, Rathmell JP, Fitzgibbon DR, Dutton RP, Michna E, Domino KB. Trends in Pain Management Liability. Anesthesiology. 2015;123:1133-41. http://www.ncbi.nlm.nih.gov/pubmed/26378399
2015 Posner KL, Severson J, Domino KB. The role of informed consent in patient complaints: Reducing hidden health care costs and improving patient engagement through shared decision making. J Healthc Risk Manag. 2015;35(2):38-45 http://www.ncbi.nlm.nih.gov/pubmed/26418139
2014 Coté CJ, Posner KL, Domino KB.: Death or Neurologic Injury After Tonsillectomy in Children with a Focus on Obstructive Sleep Apnea: Houston, We Have a Problem! Anesth & Analg 2014 June; 118(6), 1276-83 https://pubmed.ncbi.nlm.nih.gov/23842193/
2014 Coté CJ, Posner KL, Domino KB.: Death or Neurologic Injury After Tonsillectomy in Children with a Focus on Obstructive Sleep Apnea: Houston, We Have a Problem! Anesth & Analg 2014 June; 118(6), 1276-83 http://www.ncbi.nlm.nih.gov/pubmed/23842193
2014 Dutton, R.P., Lee, L.A., Stephens, L.S., Posner, K.L., Davies, J.M., Domino, K.B.: Massive Hemorrhage: A report from the Anesthesia Closed Claims Program. Anesthesiology 121:450-8, 2014. http://www.ncbi.nlm.nih.gov/pubmed/25000278
2014 Renkema E, Broekhuis M, Ahaus K. Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety.BMC Health Serv Res. 2014;14:38. Published 2014 Jan 25. doi:10.1186/1472-6963-14-38 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3905283/
2013 Kent CD, Mashour GA, Metzger NA, Posner KL, & Domino KB. Psychological impact of unexpected explicit recall of events occurring during surgery performed under sedation, regional anaesthesia, and general anaesthesia: data from the Anesthesia Awareness Registry. British Journal of Anaesthesia 110 (3): 381-7, 2013. http://www.ncbi.nlm.nih.gov/pubmed/23161356
2013 Mehta SP, Bhananker SM, Posner, KL, Domino KB. Operating Room Fires: A Closed Claims Analysis. Anesthesiology 2013 May; 118(5):1133-1139 http://www.ncbi.nlm.nih.gov/pubmed/23422795
2013 Mehta SP, Eisenkraft JB, Posner KL, Domino KB. Patient Injury From Gas Delivery Equipment: A Closed Claims Update. Anesthesiology 119(4): 778-795, 2013 http://www.ncbi.nlm.nih.gov/pubmed/23835591
2012 Olivar H, Sharar SR, Stephens LS, Posner KL, Domino KB. Similar liability for trauma and nontrauma surgical anesthesia: A Closed Claims Analysis. Anesthesia and Analgesia, 2012 Nov;115(5):1196-203. http://www.ncbi.nlm.nih.gov/pubmed/22984151
2012 The Postoperative Visual Loss Study Group. Risk Factors Associated with Ischemic Optic Neuropathy after Spinal Fusion Surgery. Anesthesiology. 2012 Jan;116(1):15-24. http://www.ncbi.nlm.nih.gov/pubmed/22185873
2011 Hindman BJ, Palecek JP, Posner KL, Traynelis VC, Lee LA, Sawin PD, Tredway TL, Todd MM, Domino KB. Cervical spinal cord, root, and bony spine injuries. A Closed Claim analysis. Anesthesiology. 2011 Apr;114(4):782-95. Accompanied by an editorial by Lanier W.L., Warner, M.A.: New perioperative cervical injury: medical and legal implications for patients and anesthesia providers. Anesthesiology 114(4):729-31, 2011. http://www.ncbi.nlm.nih.gov/pubmed/21326090
2011 Lee LA, Posner KL, Kent CD, Domino KB. Complications Associated With Peripheral Nerve Blocks: Lessons From the ASA Closed Claims Program. Int Anesthesiol Clin. 49(3):56-67, 2011. http://pubmed.gov/21697670
2011 Lee LA, Stephens LS, Fligner CL, Posner KL, Cheney FW, Caplan RA, Domino KB. Autopsy Utilization in Medicolegal Defense of Anesthesiologists. Anesthesiology 115(4):713-717, 2011. Accompanied by an editorial by McLemore JL and Garvin AJ: Autopsy and malpractice considerations. Anesthesiology 115 (4): 685-6, 2011. http://pubmed.gov/21832941
2011 Metzner J, Posner KL, Lam MS, Domino KB. Closed claims analysis. Best Pract Res Clin Anaesthesiol. 25(2):263-76, 2011. http://pubmed.gov/21550550
2011 Rathmell JP, Michna E, Fitzgibbon DR, Stephens LS, Posner KL, Domino KB. Injury and liability associated with cervical procedures for chronic pain. Anesthesiology 114(4):918-26, 2011. http://pubmed.gov/21386702
2010 Cheney FW. The American Society of Anesthesiologists Closed Claims Program: the beginning. Anesthesiology 113(4):957-60, 2010. http://pubmed.gov/20823758
2010 Fitzgibbon DR, Rathmell JP, Michna E, Stephens LS, Posner KL, Domino KB. Malpractice claims associated with medication management for chronic pain. Anesthesiology 112(4):948-56, 2010. http://pubmed.gov/20234314
2010 Ramamoorthy C, Haberkern CM, Bhananker SM, Domino KB, Posner KL, Campos JS, Morray JP. Anesthesia-related cardiac arrest in children with heart disease: data from the Pediatric Perioperative Cardiac Arrest (POCA) registry. Anesth Analg. 110(5):1376-82, 2010. http://pubmed.gov/20103543
2009 Bhananker SM, Liau DW, Kooner PK, Posner KL, Caplan RA, Domino KB. Liability related to peripheral venous and arterial catheterization: a closed claims analysis. Anesth Analg. 109(1):124-9, 2009. http://pubmed.gov/19377051
2009 Davies JM, Posner KL, Lee LA, Cheney FW, Domino KB. Liability associated with obstetric anesthesia: a closed claims analysis. Anesthesiology. 110(1):131-9, 2009. http://pubmed.gov/19104180
2009 Metzner J, Posner KL, Domino KB. The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anaesthesiol. 22(4):502-8, 2009. http://pubmed.gov/19506473
2008 Lee LA, Posner KL, Cheney FW, Caplan RA, Domino KB: Complications associated with eye blocks and peripheral nerve blocks: an American Society of Anesthesiologists closed claims analysis. Reg Anesth Pain Med 33(5):416-22, 2008. http://pubmed.gov/18774510
2007 Bhananker SM, Ramamoorthy C, Geiduschek JM, Posner KL, Domino KB, Haberkern CM, Campos JS, Morray JP. Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg. 105(2):344-50, 2007. http://pubmed.gov/17646488
2007 Jimenez N, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. An update on pediatric anesthesia liability: a closed claims analysis. Anesth Analg. 104(1):147-53, 2007. http://pubmed.gov/17179260
2007 Kent CD, Domino KB. Awareness: practice, standards, and the law. Best Pract Res Clin Anaesthesiol. 21(3):369-83, 2007. http://www.ncbi.nlm.nih.gov/pubmed/17900015
2006 Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. Injury and Liability Associated with Monitored Anesthesia Care: A Closed Claims Analysis. Anesthesiology 104(2):228-234, 2006. http://pubmed.gov/16436839
2006 Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB. Trends in Anesthesia-related Death and Brain Damage: A Closed Claims Analysis. Anesthesiology 105(6):1081-1086, 2006. http://pubmed.gov/17122570
2006 Lee LA, Roth S, Posner KL, Cheney FW, Caplan RA, Newman NJ, Domino KB. The American Society of Anesthesiologists Postoperative Visual Loss Registry: Analysis of 93 Spine Surgery Cases with Postoperative Visual Loss. Anesthesiology, 105(4):652-659, 2006. http://www.ncbi.nlm.nih.gov/pubmed/17006060
2006 Robbertze R, Posner KL, Domino KB. Closed claims review of anesthesia for procedures outside the operating room. Current Opinion in Anesthesiology. 19(4):436-442, 2006. http://pubmed.gov/16829728
2005 Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the Difficult Airway: A Closed Claims Analysis. Anesthesiology 103(1):33-39, 2005. http://pubmed.gov/15983454
2004 Domino KB, Bowdle TA, Posner KL, Spitellie PH, Lee LA, Cheney FW. Injuries and Liability Related to Central Vascular Catheters: A Closed Claims Analysis. Anesthesiology 100(6):1411-1418, 2004. http://pubmed.gov/15166560
2004 Fitzgibbon DR, Posner KL, Domino KB, Caplan RA, Lee LA, Cheney FW: Chronic pain management: American Society of Anesthesiologists Closed Claims Program. Anesthesiology 100(1):98-105, 2004. http://pubmed.gov/14695730
2004 Lee LA, Posner KL, Domino KB, Caplan RA, Cheney FW. Injuries associated with regional anesthesia in the 1980s and 1990s: a closed claims analysis. Anesthesiology 101(1):143-152, 2004. http://pubmed.gov/15220784
2002 Posner KL, Geiduschek J, Haberkern CM, Ramamoorthy C, Hackel A, Morray JP. Unexpected cardiac arrest among children during surgery, a North American registry to elucidate the incidence and causes of anesthesia related cardiac arrest. Qual Saf Health Care. 11(3):252-7, 2002 http://www.ncbi.nlm.nih.gov/pubmed/12486990
2000 Morray JP, Geiduschek JM, Ramamoorthy C, Haberkern CM, Hackel A, Caplan RA, Domino KB, Posner K, Cheney FW. Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry. Anesthesiology 93(1):6-14, 2000. http://pubmed.gov/10861140
1999 Cheney FW, Domino KB, Caplan RA, Posner KL: Nerve injury associated with anesthesia: A closed claims analysis. Anesthesiology 90: 1062-1069, 1999. http://pubmed.gov/10201678
1999 Domino KB, Posner KL, Caplan RA, Cheney FW: Airway injury during anesthesia. A closed claims analysis. Anesthesiology 91:1703-1711, 1999. http://pubmed.gov/10598613
1999 Domino KB, Posner KL, Caplan RA, Cheney FW: Awareness during anesthesia: A closed claims analysis. Anesthesiology 90: 1053-1061, 1999. http://pubmed.gov/10201677
1997 Caplan RA, Vistica MF, Posner KL, Cheney FW: Adverse anesthetic outcomes arising from gas delivery equipment: A closed claims analysis. Anesthesiology 87: 741-8, 1997. http://pubmed.gov/9357874
1996 Posner KL, Caplan RA, Cheney FW: Variation in expert opinion in medical malpractice review. Anesthesiology 85:1049-54, 1996. http://pubmed.gov/8916822
1994 Cheney FW, Posner KL, Caplan RA, Gild WM: Burns from warming devices in anesthesia. Anesthesiology 80:806-810, 1994. http://pubmed.gov/8024134
1994 Sivarajan M, Posner KL, Caplan RA, Gild WM, Cheney FW: Substance abuse among anesthesiologists: I. [Letter to the Editor]. Anesthesiology 80:704, 1994. http://pubmed.gov/8141473
1993 Morray JP, Geiduschek JM, Caplan RA, Posner KL, Gild WM, Cheney FW: A comparison of pediatric and adult anesthesia closed malpractice claims. Anesthesiology 78:461-467, 1993. http://pubmed.gov/8384428
1992 Gild WM, Posner KL, Caplan RA, Cheney FW: Eye injuries associated with anesthesia. Anesthesiology 76:204-208, 1992. http://pubmed.gov/1736697
1991 Caplan RA, Posner K, Cheney FW: Effect of outcome on physician judgments of appropriateness of care. JAMA 265:1957-1960, 1991. http://pubmed.gov/2008024
1991 Chadwick HS, Posner KL, Caplan RA, Ward RJ, Cheney FW: A comparison of obstetric and nonobstetric anesthesia malpractice claims. Anesthesiology 74:242-249, 1991. http://pubmed.gov/1990900
1991 Cheney FW, Posner KL, Caplan RA: Adverse respiratory events infrequently leading to malpractice suits. Anesthesiology 75:932-939, 1991. http://pubmed.gov/1741513
1990 Caplan RA, Posner KL, Ward RJ, Cheney FW: Adverse respiratory events in anesthesia: A closed claims analysis. Anesthesiology 72:828-833, 1990. http://pubmed.gov/2339799
1990 Kroll DA, Caplan RA, Posner K, Ward RJ, Cheney FW: Nerve injury associated with anesthesia. Anesthesiology 73:202-207, 1990. http://pubmed.gov/2382845
1990 Posner KL, Sampson PD, Caplan RA, Ward RJ, Cheney FW: Measuring interrater reliability among multiple raters: An example of methods for nominal data. Statistics in Medicine 9:1103-1115, 1990. http://pubmed.gov/2244082
1989 Cheney FW, Posner K, Caplan RA, Ward RJ: Standard of care and anesthesia liability. JAMA 261:1599-1603, 1989. http://pubmed.gov/2918653
1989 Tinker JH, Dull DL, Caplan RA, Ward RJ, Cheney FW: Role of monitoring devices in prevention of anesthetic mishaps: A closed claims analysis. Anesthesiology 71:541-546, 1989. http://pubmed.gov/2508510
1988 Caplan RA, Posner K, Ward RJ, Cheney FW: Peer reviewer agreement for major anesthetic mishaps. Quality Review Bulletin 14:363-368, 1988. https://pubmed.ncbi.nlm.nih.gov/3146042/
1988 Caplan RA, Ward RJ, Posner K, Cheney FW: Unexpected cardiac arrest during spinal anesthesia: A closed claims analysis of predisposing factors. Anesthesiology 68:5-11, 1988. http://pubmed.gov/3337390

Date of last update: March 14, 2025