The goal is to create an environment in which an open discussion can be held in order to help to understand what happened and why. Towards this end detailed records are kept to a minimum. Discussions are kept focused and not allowed to drift into areas not relevant to the investigation.
All deaths related to anesthesia and/or surgery are reported to the Medical Examiner's Office. This includes:
(1) death in the operating room
(2) death within 24 hours of surgery
(3) death linked to an anesthetic agent regardless of time (may be weeks later)
All healthcare providers involved in the case are notified of the review process and are invited to participate.
An intense investigation is conducted if:
(1) the patient was classified as a non-emergent ASA Class I, II or III
(2) there is an event that contributed to the death such as equipment failure, incorrect drug administration, difficult intubation, etc.
(3) gross error or neglect is evident
A less intense investigation is conducted if the patient was ASA Class IV or V or if the case was an emergency.
It is essential that all unexplained deaths have a complete postmortem examination, including toxicological screen.
The results of the investigation are shared between the hospital death review committee and the investigating medical examiner.
