Anesthesia must be carefully monitored, documented to lessen legal risk

NAPLES, Fla. — Ophthalmologists should document all aspects of anesthesia administration to protect themselves from liability should an anesthesia-related complication arise, according to a specialist speaking here.

Anne M. Menke, RN, PhD, a risk manager for the Ophthalmic Mutual Insurance Company, discussed the ophthalmologist's responsibilities regarding anesthesia at the Florida Society of Ophthalmology annual meeting.

When administering or overseeing the administration of anesthesia during surgery, surgeons should choose their anesthesiologist carefully, inform the patient of all associated risks and document all of these actions, she said.

"Even if you do not provide the anesthesia yourself, you're being held liable for informed consent for it," Dr. Menke said.

If a suit is filed, "the entire process of care will be evaluated," so preparation must begin before the procedure, she said. "They're not going to just look at what the complication was."

Before proceeding with surgery, ophthalmologists should first document why the procedure is medically necessary. They should also be confident in the patient's preoperative health evaluation, whether completed by them or by a primary care physician, Dr. Menke said.

Patients must also be fully informed and sign their consent forms, even if they are undergoing a second-eye procedure. Additionally, the surgeon should be fully knowledgeable of the professionals chosen to administer anesthesia and should document which drugs are used and the reasons for using those drugs, she noted.

"If you know or should have known another provider is incompetent, you are liable," Dr. Menke said.

Postoperatively, Dr. Menke recommended full disclosure to the patient of any complications experienced during surgery.

"As soon as you can, tell the patient there was a complication. Document the conversation. Put it in your operating notes," she said.