Abstract
We reviewed and report a case of criminal medical malpractice from 2008. A corrugated tube was accidentally disconnected from a patient and adverse events occurred while the anesthesiologist in charge was called away from the operating room to aid another physician. The in-hospital investigative commission concluded that the reason the tube was disconnected could not be determined, and that the surgeons in the operating room did not hear the alarm sound. The anesthesiologist was prosecuted based on the guideline “an anesthesiologist should stay beside the patient and consistently monitor him/her.” The judge, however, acquitted the anesthesiologist based on the following grounds: (1) there was no description of predictability in the indictment document; (2) the corrugated tube may have become disconnected due to the actions of other medical personnel in the operating room; (3) it is not reasonable that medical personnel in the operating room would not have heard the alarm sound; and (4) the guideline is only a recommendation of an academic society. Clinical practice guidelines had previously been assumed to be a criterion on which to determine medical standards, based on sentences handed down in preceding civil medical cases.
