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Physicians involved in pain management should be aware that there
are many legal issues involved in the practice of pain management.
Some patients who present to pain management centers may be involved
in litigation or compensation cases. The impact of these issues
on patient outcome is controversial. Patients with pain often are
labeled “difficult” because of their responses
to the stress of their pain. Furthermore, there is a widespread
perception that anesthesiologists working in pain management centers
are at a greater risk of being sued for malpractice than those working
in the traditional operating room setting.
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The available information, however, does not support this perception.
For example, during the period 1971 to 1982 in Washington State,
of 192 malpractice claims against anesthesiologists, 56 involved
regional anesthesia, but only one (for a pneumothorax during stellate
ganglion block) involved pain management.1 Data
from the claims files of the Risk Management Foundation of the Harvard
Medical Institutions shows only one anesthesia pain management claim
during a recent 10-year period. In this claim, a man received a
corticosteroid injection for meralgia paresthetica. Shortly after
leaving the hospital, approximately 50 minutes after receiving the
injection, he became dizzy. He returned to the pain clinic and fell,
allegedly sustaining a back injury that caused permanent residual
pain. The claimant alleged a failure to obtain informed consent
and that the physician did not advise him to remain for observation
for adverse reactions. The claim was resolved without a lawsuit.
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The database of the American Society of Anesthesiologists Closed
Claims Project shows that while the proportion of anesthesia malpractice
claims involving nonoperative pain management is fairly low, it
is increasing over time, from 2% of all claims in the 1970s
to 8% of all claims in the 1990s. In a review of the database
of closed claims, the most common injuries were pneumothorax, nerve
damage, headache, and back pain. Claims for very serious complications
such as brain damage or death represent a small but not insignificant
fraction (10%) of the claims. The median payment for operative
claims was much higher than the payment for nonoperative pain management
claims ($100,000 vs $16,250). The likelihood of
payment for a claim was similar between the two groups, as was reviewer
judgment of appropriateness of care.2
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Exposure to the risk of a malpractice claim will vary with the
degree of a physician’s involvement with pain management
and the type of procedures performed. The greatest risk for major
claims appears to be associated with the administration of ablative
nerve blocks.3–5
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One moderate-sized pain management center in a university teaching
hospital doing approximately 1000 procedures (nearly all injections)
annually had the following distribution of case mix: lumbar epidural
steroids, 66%; epidural narcotic catheters, 1%;
transcutaneous electrical nerve stimulation (TENS), 2%;
stellate ganglion, 6%; facet, 3%; and blood patch,
1%. Only a few blocks performed during this period were
neurolytic. Therefore, this pain center, and other pain ...