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Improper administration of anesthesia and surgical awareness

by Laura Hale Brockway, ELS, Vice President, Marketing, and 
Stacy Agnew, MBA, Risk Management Representative

A 34-year-old man was taken to the OR by a general surgeon for a hernia repair. His case was assigned to a certified registered nurse anesthetist (CRNA) with an anesthesiologist overseeing the surgery. 

Physician action
The case started at 14:20 when the patient was given midazolam, fentanyl, rocuronium, and a bolus of propofol for induction and rapid sequence intubation. After approximately 35 minutes, the CRNA realized that the propofol infusion line was not connected to the patient’s IV line. He gave an inhalation agent to the patient. 

After the surgery, the anesthesiologist asked the patient if he remembered anything from surgery. The patient said that he woke soon after intubation. Though he remained paralyzed, he was aware of being operated on and was unable to communicate. The patient said he was able to feel the surgeon operating on his abdomen and that he experienced excruciating pain. 

The CRNA documented the following in the anesthesia record: 

“Patient high risk PONV [postoperative nausea and vomiting]. Decided to use TIVA [total intravenous anesthesia]. Propofol thought to be infusing at the charted rate. Noted purposeful movement with head. Increased propofol infusion. Additional propofol pushed. Additional narcotic and Versed given as charted. Removed eye tape, no tears noted. Patient not attempting to open eyes. 1442 Dr. [anesthesiologist] at bedside. Inhalation agent started. 1455 patient pillow wet. Propofol infusion discovered not connected. Propofol infusion connected. Inhalation agent increased. Dr. [anesthesiologist] at bedside. HR and BP stable as noted in record . . . In PACU patient waking up, opening eyes, calm . . . states minimal discomfort . . . I spoke with the patient after Dr. [anesthesiologist] had.” 

The anesthesiologist documented the following: 

“[CRNA] requested me in room after a strange motion in the patient. It appeared it could have been purposeful so we started gas. 10 or 15 minutes later he asked me to come back to the room. He said he realized the propofol was not connected and had given Versed and connected infusion tubing. Based on his [the patient’s] HR and BP I did not think he had emerged from initial induction to have recall. I asked him in the PACU and he said he did remember pain and knew something was wrong and talking.”

A lawsuit was filed against the anesthesiologist, the CRNA, and the anesthesia group that employed them. The allegation was improper administration of anesthesia resulting in surgical awareness. The patient allegedly developed post-traumatic stress disorder and anxiety after the surgery. 

Legal implications
The anesthesiologist who reviewed this case for the plaintiff stated that the CRNA breached the standard of care by failing to connect the propofol infusion. This lack of anesthesia for the first part of the procedure likely led to surgical awareness, which caused the patient’s later symptoms of anxiety and post-traumatic stress disorder. The anesthesiologist was criticized for not discovering the unattached propofol infusion line before the start of the surgery.

When the CRNA’s actions were reviewed by defense anesthesiologists, they were unable to support his care of the patient. They primarily contended that the CRNA should have investigated the IV lines when he realized the patient was under-anesthetized. One expert stated that once the disconnected line was discovered, the defendants’ response was appropriate. 

Regarding the actions of the defendant anesthesiologist, anesthesiologists who reviewed the case stated that the standard of care did not require the defendant to double check that the CRNA set up the infusion properly. There was also testimony that the incident was not related to any failure by the anesthesiologist to supervise the CRNA or failure by the anesthesia group to properly train the CRNA. 

This case was settled on behalf of the CRNA. The case against the anesthesiologist and the anesthesiology group was dropped. 

Risk management considerations
The U.S. Department of Health and Human Services, Office of Inspector General defines an adverse event as “an event in which care resulted in an undesirable clinical outcome-an outcome not caused by underlying disease-that prolonged the patient stay, caused permanent patient harm, required life-saving intervention, or contributed to death.” While the patient underwent a successful surgery in this case, it can be argued there was harm to the patient including post-traumatic stress and anxiety as a result of medical care or in a health care setting, including the failure to provide needed care. Patient harm “refers collectively to adverse events and temporary harm events.” (1) 

Remaining factual when documenting adverse events or outcomes is imperative. In this case, the CRNA documented the events as noted and refrained from speculation or blame. 


1. U.S. Department of Health and Human Services. Office of Inspector General. Adverse Events. Updated September 7, 2023. Available at,intervention%2C%20or%20contributed%20to%20death. Accessed on October 4, 2023.

Laura Brockway can be reached at

Stacey Agnew can be reached at