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Similar Liability for Trauma and Nontrauma Surgical Anesthesia

A Closed Claims Analysis

Olivar, Hernando, MD*†; Sharar, Sam R., MD*†; Stephens, Linda S., PhD*; Posner, Karen L., PhD*; Domino, Karen B., MD, MPH*

doi: 10.1213/ANE.0b013e31826ac344
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BACKGROUND: Trauma care has many challenges, including the perception by nonanesthesia physicians of increased medical malpractice liability. We used the American Society of Anesthesiologists’ Closed Claims Project database and the National Inpatient Sample (NIS) to compare the rate of claims for trauma anesthesia care to national trauma surgery data. We also used the American Society of Anesthesiologists’ Closed Claims Project database to evaluate injury and liability profiles of trauma anesthesia malpractice claims compared to nontrauma surgical anesthesia claims.

METHODS: Surgical anesthesia claims for injuries that occurred between 1980 and 2005 in the American Society of Anesthesiologists’ Closed Claims Project database of 8954 claims were included in this analysis. Trauma was defined using cause of injury criteria in state trauma registries, including out-of-hospital falls. To estimate national trauma anesthesia rates, we used injury codes in NIS reports to define trauma discharges and NIS discharges with surgical procedure codes for the denominator. The year-adjusted odds ratio and P value comparing the national trauma anesthesia injury rates and American Society of Anesthesiologists’ Closed Claims Project inpatient claim rates in the 1990 to 2001 time period were calculated by a multivariate logistic regression of the injury/trauma outcome on year and the NIS/Closed Claims Project indicator. Payments in claim resolution between trauma claims and nontraumatic surgical anesthesia claims were compared by χ2 analysis, Fisher exact test for proportions, and Kolmogorov–Smirnov test for payment amounts.

RESULTS: Trauma claims represented 6% of the total 6215 surgical anesthesia claims in the study period. The inpatient trauma claims rates were consistently lower than the NIS injury rates for 1990 to 2001. The year-adjusted odds ratio comparing the trauma claims rates to the NIS injury rates was 0.62 (95% confidence interval [CI], 0.53 to 0.72; P < 0.001, likelihood ratio test). Trauma claims and nontrauma surgical anesthesia claims did not differ in appropriateness of care, whether or not a payment was made to the plaintiff, or size of payments.

CONCLUSION: Despite reported perceptions that trauma care involves a high risk of medical liability, there was no apparent increased risk of liability among inpatients presenting for trauma anesthesia care. The proportion in malpractice claims in trauma anesthesia care was not increased compared to nontraumatic surgical anesthesia care. With respect to medicolegal liability, these results support participation of anesthesia providers in multidisciplinary trauma care and organized systems.

Published ahead of print September 13, 2012

From the *Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA; Harborview Medical Center, Seattle, WA.

Accepted for publication June 19, 2012.

Published ahead of print September 13, 2012

Funding: Supported by the American Society of Anesthesiologists (ASA), Park Ridge, IL, All opinions expressed are those of the authors and do not reflect the policy of the ASA.

This report was previously presented, in part, at the Trauma Anesthesia and Critical Care Symposium, San Diego, CA, May 2001; and ASA annual meeting (abstract A1362), 2003; and was the subject of an article in ASA Newsletter 2002;66(6):9–10 and 21.

The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.anesthesia-analgesia.org).

Reprints will not be available from the authors.

Address correspondence to Karen B. Domino, MD, MPH, Dept. of Anesthesiology and Pain Medicine, Box 356540, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195-6540. Address e-mail to kdomino@u.washington.edu.

Anesthesiologists frequently provide acute care for trauma victims with unstable and/or unpredictable physiologic and anatomic conditions that may impact clinical outcome, including difficult airways, cardiovascular and respiratory compromise, and severe head or spinal cord injury. Furthermore, several nonclinical factors may complicate the care of trauma victims, and temper enthusiasm for providing such care. Traumatic injuries often occur at inconvenient times (nights and weekends) when personnel and equipment resources may be less readily available, increasing the challenge and stress of trauma care.1 In addition, reimbursement rates for trauma care are low,2 and there is a long-standing perception among surgeons and other high-risk specialists that trauma care carries a high risk of malpractice liability.36 Together, these factors may limit physician participation in the design and implementation of organized trauma systems. Since trauma centers have better patient outcomes after moderate-to-severe trauma compared to care in nontrauma centers,7 physician reluctance to participate in organized trauma systems can negatively affect patient outcome.

Studies suggest that trauma surgery is not associated with increased malpractice liability compared to elective and urgent nontrauma surgery,8 or to other surgical and medical specialties.9 Although the perceptions of anesthesia providers toward trauma care are not reported in the literature, we have received anecdotal reports from anesthesiologists in the Washington State Emergency Medical Services and Trauma System that there may be increased medical liability risk associated with trauma anesthesia care. To determine whether trauma anesthesia care is associated with increased medical liability risk, we conducted an analysis of the American Society of Anesthesiologists’ (ASA) Closed Claims Project database to compare the rate of claims for trauma anesthesia care to national trauma surgery data. We also compared the liability profile of trauma anesthesia malpractice claims (complications and payments) to nontrauma surgical anesthesia claims.

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METHODS

This study was approved by the University of Washington IRB. The requirement for written informed consent was waived by the IRB. The ASA Closed Claims Project is a structured evaluation of adverse anesthetic outcomes obtained from the closed claims files of 35 United States (US) professional liability insurance companies. The data collection process has been described in detail.10,11 Each closed claim file was reviewed by a practicing anesthesiologist who completed a standardized form and narrative summary (Appendix 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A459). Information was recorded concerning patient characteristics, treatment details, sequence of events, mechanism of injury, clinical and liability outcomes, and standard of care. The current analysis included surgical anesthesia claims for events that occurred between 1980 and 2005 from the ASA Closed Claims Project database of 8954 claims. Claims associated with obstetric anesthesia care, acute pain management, and chronic pain management were excluded.

We used a review of statewide trauma registries to determine which events to classify as trauma for this analysis.12 There was extensive variation in state trauma registry inclusion criteria. We defined trauma as any cause of injury that was more commonly included than excluded among the various different state trauma definitions.12 There was substantial variation among states in their inclusion criteria for same-height falls. We included all out-of-hospital falls in our definition of trauma. A keyword search of the database’s narrative summaries used an extensive list of terms to screen for possible trauma claims (Appendix 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A460). The keyword search yielded 1457 narratives. These narratives were initially screened to eliminate any that clearly were outside our definition of trauma on the basis of the trauma registry criteria. This screening yielded 439 narratives that were subsequently reviewed by 3 anesthesiologists to determine whether the claim met our trauma definition (κ range of pairwise agreement 0.69 to 0.91). Claims were excluded if the trauma was associated with pathology (e.g., a broken bone in a patient with osteosarcoma). Three hundred ninety-five claims were determined to be trauma-related.

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Measures

After identifying the trauma-related claims, every narrative was read independently by 2 of 3 anesthesiologists to identify the etiology of the trauma, the site or sites of the initial trauma experienced by the patient, and the amount of time that passed between the trauma event and the provision of anesthetic care. If there was disagreement between the 2 assigned anesthesiologists, that claim was then evaluated by the third anesthesiologist. A third anesthesiologist assessment was required in fewer than 10% of evaluations of etiology and site of trauma, and approximately 20% of evaluations of the time period between the trauma event and provision of anesthesia care. If necessary, the anesthesiologists met to discuss and classify any particularly difficult claims.

The etiology of the trauma was defined as the mechanism by which the traumatic event occurred and consisted of 15 categories such as motor vehicle accident, fall from a height (e.g., a ladder or a tree), or penetrating or lacerating injury. A complete list of these mechanisms is contained in Appendix 2 (see Supplemental Digital Content 2, http://links.lww.com/AA/A460). The amount of time that passed between the trauma event and the provision of anesthetic care was divided into the following categories: <24 hours, 24 to <48 hours, 48 hours to less than 1 week, 1 week to less than 2 weeks, 2 weeks to less than 1 month, 1 month or more, and no indication of how much time passed between the traumatic event and the provision of anesthetic care. In claims with no explicit statement of timing between the traumatic event and provision of anesthesia care, we classified the time period as <24 hours for incomplete spinal cord injury or open globe and <48 hours for fractures to the hip, femur, or ankle. All other claims lacking explicit statements of timing were classified as unknown.

The severity of the adverse outcome resulting in the malpractice claim was determined using the insurance industry’s 10-point scale, which ranges from 0 (no obvious injury) to 9 (death). Injuries were grouped into temporary/nondisabling injury (0–5), permanent/major injury (6–8), and death (9) for this analysis. Severe brain damage was identified as claims in which brain damage occurred and the severity score was 6 to 8.

The damaging event was defined as the mechanism by which an injury or complication occurred. The specific damaging events were collapsed into the following categories: respiratory events, cardiovascular events, equipment events, regional block events, medication-related events, and other events (e.g., surgical and/or patient condition, wrong operation/location/patient, positioning/padding).

Appropriateness of anesthetic care was rated as appropriate (standard), substandard, or impossible to judge on the basis of reasonable or prudent practice at the time of the event. A previously published study found reliability of these judgments to be acceptable.13 Payments were adjusted to 2008 dollar amounts using the Consumer Price Index.a

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National Sample

We used data from the National Inpatient Sample (NIS) to compare the trauma claims rate to the trauma discharge rate on a national level. As NIS data are restricted to inpatients, we compared national trauma data to inpatient trauma and surgical claims from the ASA Closed Claims Project database. For the national data, NIS trauma discharges were defined by specific injury codes in the primary diagnosis14 (Appendix 2, specific ICD-9-CM codes used, see Supplemental Digital Content 2, http://links.lww.com/AA/A460). We used the NIS annual reports for our denominator of surgical discharges (Appendix 2, specific ICD-9-CM codes included/excluded as surgical; see Supplemental Digital Content 2, http://links.lww.com/AA/A460).1527 Any discharge with at least 1 surgical procedure listed was included as a surgical discharge in those reports. Data for 1990 through 2001 were included in this analysis.

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Statistical Analysis

Kappa was used to assess agreement on etiology of trauma (range of pairwise agreement, 0.82 to 0.90), site of trauma (κ range, 0.78 to 0.86), and time between traumatic event and anesthetic care (κ range, 0.69 to 0.75). We compared liability characteristics (severity of injury, appropriateness of care, proportion with payment, size of payment) between trauma claims and nontrauma surgical claims by Fisher exact test and Kolmogorov–Smirnov test (payment amount) using P < 0.05 for statistical significance. When the overall P value for an entire contingency table with more than 2 groups was significant, post hoc Fisher exact tests and the Bonferroni correction were used to adjust for multiple tests. P values are stated before correction. Because payments were not distributed normally, the median and range are reported for all claims for which a payment was made. The estimated quantiles of payment distributions of trauma and nontrauma surgical claims were plotted against one another in a QQ plot. The QQ plot included the theoretical identity line that would result if payment distributions were identical. Data were not transformed for analysis; a logarithmic scale was used for clarity of illustration.

For comparison of the inpatient trauma claims rate to the national inpatient injury rate, the trauma claims rate was defined as the number of inpatient trauma claims divided by the total number of inpatient surgical claims in the ASA Closed Claims Project database each year. The rate of national trauma discharges was defined as the number of trauma discharges divided by the number of surgical discharges as defined above. The year-adjusted odds ratio and P value comparing the NIS and ASA Closed Claims Project rates in the 1990 to 2001 time period were calculated by a multivariate logistic regression of the injury/trauma outcome on year and the NIS/Closed Claims Project indicator. Further details on the logistic regression models are provided in Appendix 2 (see Supplemental Digital Content 2, http://links.lww.com/AA/A460). The 95% confidence intervals for the overall NIS and ASA Closed Claims Project injury/trauma rates were calculated using the exact binomial confidence interval.28

All statistical analysis of ASA Closed Claims Project trauma versus other surgical claims was conducted with PASW Statistics 18.0.3 (IBM Corporation, Somers, NY). The QQ Plot was created in R 2.14.0 (The R Foundation for Statistical Computing, Vienna, Austria). Analysis comparing NIS to ASA Closed Claims Project data was performed in R 2.14.0 (The R Foundation for Statistical Computing, Austria, Vienna).

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RESULTS

General Description

Claims associated with trauma anesthesia care represented 6% of 6215 surgical anesthesia claims in the study period. The characteristics of patients in trauma and nontrauma surgical claims are shown in Table 1. The etiology of trauma and anatomic locations of injury in trauma claims are shown in Table 2.

Table 2

Table 2

Table 1

Table 1

The most frequent known trauma etiology was motor vehicle accidents (23%), followed by falls (18%), and penetrating/lacerating injuries (15%; Table 2). In 38% of claims the etiology of trauma was unknown. Most (87%) claims with unknown etiology of trauma included fractures to at least one bone. Other claims with unknown trauma etiology were lacerations and blunt abdominal trauma. The majority of trauma claims (73%) involved anesthesia care provided <48 hours after injury. Very few (n = 5) trauma claims involved anesthesia care provided in the emergency room; most (65%) trauma claims were associated with anesthesia care in the operating room.

Death was more common in trauma claims (46% vs 32%, P < 0.001), and temporary injuries were less common (P < 0.001) compared to nontrauma surgical anesthesia claims (Fig. 1). The specific outcomes such as airway injuries, awareness during anesthesia, brain damage, eye damage, myocardial infarction, nerve injuries including peripheral nerve injury and spinal cord injury, skin injuries, and stroke were similar between trauma and nontrauma surgical anesthesia claims (Table 3). Table 4 shows the damaging events in trauma claims compared to other surgical claims. The proportion of difficult intubation, esophageal intubation, aspiration of gastric contents, excessive blood loss, inadequate fluid management, peripheral or central catheters, wrong blood, wrong drug or dose, and wrong operation/location/patient were similar in trauma compared to other surgical claims (Table 4).

Table 4

Table 4

Table 3

Table 3

Figure 1

Figure 1

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Liability Profile

There was no difference between the trauma and nontrauma claims in the proportion of claims with substandard anesthesia care or payment made to the plaintiff (Table 5). In nearly half (47%, 95% CI, 42%–52%) of trauma claims the anesthesia care was appropriate, while anesthesia care was substandard in 38% of trauma claims (95% CI, 33%–43%). Payment was made to the plaintiff in 59% of trauma claims (95% CI, 54%–64%), similar to nontrauma surgical claims, with a median payment of $298,000 (Table 5). Figure 2 illustrates a QQ plot of payments in trauma versus nontrauma claims. Most data points are close to the identity line, indicating similarity in the distribution of payment amounts in trauma and nontrauma surgical claims.

Table 5

Table 5

Figure 2

Figure 2

The overall inpatient trauma claims rate between 1990 and 2001 was 8.85 (95% CI, 7.65 to 10.16). The overall national inpatient injury rate during this same time period was 13.60 (95% CI, 13.59 to 13.60). The trauma claims rates were consistently lower than the NIS injury rates for all years (Fig. 3). The year-adjusted odds ratio comparing the trauma claims rate to the NIS injury rates was 0.62 (95% CI, 0.53 to 0.72; P < 0.001, likelihood ratio test). The interaction between the claims rate–NIS injury rate difference and year was not statistically significant (P = 0.9, likelihood ratio test).

Figure 3

Figure 3

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DISCUSSION

According to the Centers for Disease Control and Prevention, in 2004 traumatic injury in the US resulted in 167,000 deaths and 1.9 million hospitalizations.29 Because a significant fraction of these hospitalized patients require emergent resuscitation and/or acute surgical treatment for either temporary stabilization or definitive injury repair, anesthesiologists are frequently involved in acute trauma care. Such participation often occurs in the setting of organized trauma systems that involve designated and verified trauma centers with multidisciplinary trauma teams that include anesthesiologists. Trauma center care is reported to be beneficial in terms of both patient outcomes and economic value. Both in-hospital mortality and 1-year mortality rates were reported to be significantly lower in a large national sample of trauma patients, particularly those with severe (i.e., operative) injuries, receiving care in trauma centers versus nontrauma centers.7 In addition, the incremental savings in cost per life-year for treatment at a US trauma center compared to a nontrauma center was recently estimated to be $36,319 ($790,931 per life saved).30

Despite these societal benefits of organized, multidisciplinary trauma care, physician specialists in general surgery, orthopedic surgery, neurosurgery, and emergency medicine report a reluctance to participate in trauma care systems because of the unsavory type of patients encountered,3 substandard reimbursement,4,5 off-hour responsibilities that interfere with elective surgery,4,5 and fears of increased medicolegal liability (not specifically reported as increased risk of claim, magnitude or payment, or other factor).36 Interestingly, perceptions of anesthesiologists toward trauma care are not reported in the literature; however, we have received anecdotal reports in the Washington State trauma system of multiple specialist physicians, including anesthesiologists, lobbying their hospitals to not participate in the trauma system for all reasons stated above. The current study attempted to further inform this issue by documenting potential differences in malpractice liability between trauma and nontrauma care specific to anesthesia care. We found that trauma claims rates were consistently lower than NIS injury rates, with an odds ratio of 0.62, which suggests that there may be a lower risk of a lawsuit for trauma compared to nontrauma surgical anesthesia care.

There are well-described limitations inherent to analysis and interpretation of data in the ASA Closed Claims Project database, including selection bias, retrospective data collection, and lack of denominator data.11 We used national hospital survey data to estimate the rate of trauma anesthesia for comparison to the trauma claims rate in the ASA Closed Claims Project database. Our estimate of national trauma anesthesia rates may be high if some patients with injury codes in the NIS data did not have procedures with anesthesia. While the majority of trauma claims (73%) had <48 hours between the trauma and anesthesia care, some were not acute trauma care. The 48-hour treatment timing was based on an estimate in some trauma claims for lower-extremity fractures, so it must be interpreted with caution. The demographic characteristics and anatomical distribution of injuries in our study population were both generally similar to the national demographics and injury patterns of patients sustaining traumatic injuries,29 suggesting that trauma patients in the database are representative of the larger US population. However, some epidemiologic characteristics of our study population differed from those of the national trauma population; specifically, the most frequent mechanisms of injury in our study were motor vehicle accidents (23%), falls (18%), and penetrating lacerating injuries (15%), compared with frequencies of 12%, 26%, and 8%, respectively, in the national trauma population.29

The results of the current study for anesthesiologists providing trauma anesthesia care are consistent with previous reports in the surgical literature indicating no increased malpractice liability risk for trauma surgeons providing acute trauma care,8,9 despite surgeons’ perceptions to the contrary.36 One high-volume academic surgery/trauma center has reported a significantly higher indemnity payment (per 1000 admissions) for malpractice claims made by trauma patients compared to those undergoing elective cardiothoracic or women’s surgery, although the incidence of adverse events in all 3 groups was not different.31 Fear of malpractice liability is a significant factor that determines physician participation in trauma care.32 However, reluctance to participate in trauma care because of malpractice risk appears to be unfounded and can negatively impact access to care through organized trauma systems.33 Results of the current study provide objective evidence that anesthesiologists should consider before deciding whether to participate in such trauma care systems.

The appropriateness of the anesthesia care provided to patients in the trauma claims group was not different from that of patients in the nontrauma claims group, suggesting that despite the challenge of managing severely ill trauma patients in typically more emergent settings, anesthesia care standards are maintained.

While trauma claims more frequently involved patient death than other surgical claims, the proportion of other outcomes was similar in the 2 groups. This is somewhat surprising as some injuries are more common in the emergency setting, such as awareness during anesthesia34 and pharyngoesophageal perforation.35 Similarly, damaging events that theoretically might be expected to occur more frequently in the acute care of trauma patients—such as difficult intubation, aspiration of gastric contents, excessive blood loss, inadequate fluid administration, medication and blood administration errors, and wrong operation/location/patient—were also not different between trauma and other surgical claims, despite the increased proportion of emergency procedures. These data suggest that causes of adverse outcomes are fairly similar between trauma and nontrauma surgical anesthesia claims.

The acute trauma setting does not always allow adequate time in the preanesthesia period to develop a firm physician–patient relationship, nor to adequately establish realistic expectations in patients and family members regarding outcomes of care, both of which have been reported to mitigate the frequency of medical malpractice claims.36 Patient and family expectations in the trauma population are particularly difficult to manage in the absence of a preinjury physician–patient relationship, and because of the unpredictable nature of the disease process and long-term recovery, uncertain injury effects on return to work and family obligations, and anger that frequently accompanies recovery.31 However, despite these limitations in the trauma setting, medical liability profiles were not different in trauma claims compared to nontrauma surgical claims.

The proportion of claims resulting in malpractice payment did not differ in the trauma and nontrauma surgical claims group. Negligence (substandard care) is a precondition of payment in malpractice claims in the tort system. The proportion of payment made is dependent upon the extent of deviation from the standard of care, with payments more likely in substandard care than with appropriate care.10 Payment amounts are also dependent upon severity of injury, with highest amounts for permanent disabling injuries that may require long-term care.10 Our finding of similar payment rates and amounts between trauma and nontrauma claims despite a higher rate of death is of interest in light of previous evidence that the severity of patient disability, rather than the mere occurrence of an adverse event, is predictive of payment to the plaintiff.37

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CONCLUSION

Traumatic injury results in millions of nonfatal injuries annually in the US, many of which require acute surgical intervention, including resuscitative and perioperative care by anesthesia providers. The common perception that trauma care involves a high risk of malpractice liability is one factor that has discouraged physicians and institutions from participating in trauma care. The results of our study suggest no increased risk of a malpractice claim from trauma anesthesia care compared to other surgical care and demonstrate no difference in whether a payment was made to the plaintiff, or the magnitude of claim payments between trauma anesthesia-related claims and nontrauma surgical anesthesia claims. These findings refute the perceived high risk of malpractice liability specifically related to anesthesiologist participation in multidisciplinary trauma care. With respect to medicolegal liability, these results support participation of anesthesiologists in multidisciplinary trauma care and organized trauma systems.

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DISCLOSURES

Name: Hernando Olivar, MD.

Contribution: This author helped conduct the study and write the manuscript.

Attestation: Hernando Olivar has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Sam R. Sharar, MD.

Contribution: This author helped design the study, conduct the study, and write the manuscript.

Attestation: Sam R. Sharar has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Linda S. Stephens, PhD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Linda S. Stephens has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Karen L. Posner, PhD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Karen L. Posner has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Karen B. Domino, MD, MPH.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Karen B. Domino has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

This manuscript was handled by: Steven L. Shafer, MD.

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ACKNOWLEDGMENTS

The authors acknowledge the contributions of Y.K. Tsai, MD, and Lorri Lee, MD, who helped with design of this study, and Lynn Akerlund who provided secretarial assistance. We also acknowledge the closed-claims reviewers from the ASA and participation of the following liability insurance companies who have given permission to be acknowledged: Anesthesia Service Medical Group, Inc., San Diego, California; Armed Forces Institute of Pathology, Silver Spring, Maryland; COPIC Insurance Company, Denver, Colorado; Daughters of Charity Health Systems, St. Louis, Missouri; Department of Veterans Affairs, Washington, DC; ISMIE Mutual Insurance Company, Chicago, Illinois; MAG Mutual Insurance Company, Atlanta, Georgia; Medical Liability Mutual Insurance Company, New York, New York; Midwest Medical Insurance Company, Minneapolis, Minnesota; Mutual Insurance Company of Arizona, Phoenix, Arizona; NORCAL Mutual Insurance Company, San Francisco, California; PMSLIC Insurance Company, Mechanicsburg, Pennsylvania; Physicians Insurance A Mutual Company, Seattle, Washington; Preferred Physicians Medical Risk Retention Group, Shawnee Mission, Kansas; ProMutual (Medical Professional Mutual Insurance Company), Boston, Massachusetts; Risk Management Foundation, Cambridge, Massachusetts; State Volunteer Mutual Insurance Company, Brentwood, Tennessee; The Doctors’ Company, Napa, California; The University of Texas System, Austin, Texas; Utah Medical Insurance Association, Salt Lake City, Utah.

a Consumer Price Index Inflation Calculator. U.S. Department of Labor, Bureau of Labor Statistics. Available at http://www.bls.gov/data/home.htm. Accessed January 21, 2010.
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