Summary of the California blue ribbon panel report on anesthesia

At the request of the Dental Board of California, a panel reviewed mortality data from the Dental Board, lawsuits from a major California malpractice insurance company, anesthesia regulations from other states, and the published scientific literature. In California between 1991 and 2000, there were 12 deaths related to general anesthesia permits, 0 deaths related to conscious sedation permits, and 8 deaths related to nonpermit holders (four deaths with oral sedation in children and four deaths with local anesthesia alone). The panel was concerned about the increased use of repeated oral or sublingual doses of sedatives and recommended a certificate process. The panel recommended a standing committee to access significant anesthesia/sedation-related misadventures and to determine how such mishaps could be prevented. The data reviewed and recommendations made are summarized in this report.