June 5, 2007
We frequently see hospital systems focus the bulk of their patient safety activity on the inpatient side. Historically, there have always been fewer serious adverse events in the ambulatory surgery suite, whether hospital-based or free-standing, than in acute care hospital operating rooms. This, of course, largely reflects the relatively good overall health of the patient population and the fact that procedures are generally less complex than those done in acute care settings. Nevertheless, serious incidents can occur in ambulatory surgery settings and there are certain factors unique to these settings that may predispose to certain kinds of error. In fact, more than half of the wrong-site surgeries reported to Joint Commission have occurred in ambulatory surgery sites.
One factor is that a surgeon will often be performing many cases of the same or similar procedures. Interestingly, very experienced surgeons may be more likely to be involved in wrong-site cases, perhaps because their experience allows them to schedule so many cases in one day.
The quality of the medical records is often not as good in ambulatory settings. The “facility” medical record is often scant and the physician often brings in his/her office notes that are “unofficial” as far as the facility is concerned. Often critical information is in the physician office record and never appears in the facility medical record. It is therefore incumbent upon the facility and entire team to ensure the adequacy of the medical record and all documentation prior to the procedure.
Another practice that should be frowned upon is allowing the medical records of multiple patients to be in the operating room. We’ve seen instances where a surgeon might bring in a stack of office charts on all the patients on that day’s ambulatory schedule. The system should never allow one to mistakenly pick up the chart of the wrong patient during a procedure. The same applies to other things a physician might bring in for all the day’s patients (eg. X-rays, scans, implants, etc.). The rule should be that all the things in the OR apply to only the patient on the table.
And there are certain production pressures unique to the ambulatory setting. When a surgeon is booked for many cases in one day, there is a higher likelihood of last-minute changes in the schedule. Also, we’ve seen cases in the ambulatory setting where one patient may demand a procedure earlier in the day, leading to last-minute alterations in the order on the schedule. And lastly, the pressure to get cases done promptly and stay on schedule are everpresent.
Remember that all elements of the Joint Commission Universal Protocol apply equally to the ambulatory setting. And keep in mind that the verification process must take place at multiple points preoperatively, including at the time the procedure is scheduled.
Availability of all appropriate documents at the “timeout” is essential. They should be reviewed for actual content rather than simply acknowledging their presence and there should be agreement by all on what the documents say rather than simply having individual review of the documents. And, of course, good communication among all team members, utilization of hearback, requiring agreement of all team members before proceding, and involvement of the patient and/or family are all important in ensuring safe outcomes.
Organizations should utilize some of the resources available for patient safety in the ambulatory surgery setting. The American Academy of Ophthalmology has issued good guidance statements on avoiding wrong-site surgery and avoiding incorrect intraocular lens placement , with good examples of how checklists might be utilized. And the American Academy of Orthopedic Surgeons also has very good resources.
Overall compliance with the “timeout” requirements of Joint Commission’s patient safety goals for ambulatory surgery is still only in the 80% range so organizations should take a hard look there.
Joint Commission is also finding less than full compliance in ambulatory surgery on several medication-related goals (eg. medication reconciliation, labeling medications and solutions, “do not use” abbreviations, and look-alike/sound-alike drugs). We’ll address some of those issues in future Tips of the Week.