Life-threatening situations can occur in your program

Case studies show what can go wrong

There are some situations that come up repeatedly in ambulatory surgery settings that can be life threatening, warns Anne Dean Schilling, RN, BSN, consultant with The ADA Group, a DeLand, FL-based consulting firm specializing in ambulatory surgical development and regulatory compliance.

One of those situations is hesitating to tell physicians, particularly if they are owners, that they can't schedule a specific procedure at your facility, Schilling says.

She points to a case involving a 48-year-old patient who came in for a face lift, vein stripping, and liposuction. Other than having asthma, the patient was healthy. The center didn't allow any procedures that were scheduled to go longer than five hours. When the nurse scheduled the case, "she asked for five hours, but knew he couldn't get it done in five hours," Schilling says. The case took 11½ hours, she says. The patient was sent home at the end of the day, had a pulmonary emboli, and died, Schilling says.

You can establish criteria such as how long a procedure must be, but you must ensure that it is implemented and enforced, she says. Many staff members hesitate to enforce a policy when the physician owns part of the center, Schilling says. "The board needs to say, 'Our first job is to have a place that's safe for the patient,'" she says. When Schilling helps set up a new surgery center, she tells nurses that their first job is to protect the doctor. "Don't let him do things that put him at risk or patients at risk," she says.

It's often said that a nurse is the patient's last bastion of safety in the OR, Schilling says. "I thought, 'That's true,' when I heard it," she says. "It's also true when the physician is the owner."

Another problem that crops up repeatedly in ambulatory surgery programs is the failure to communicate critical patient information at handoff, Schilling says.

She points to a case in which a cataract patient was oxygen-dependent. The pre-op nurse noted the patient was oxygen-dependent. However, in the hectic turnover of cases, the patient went into the OR without an anesthesia preoperative assessment. The nurse noticed this omission; she called the certified registered nurse anesthetist (CRNA) in the OR and asked, "Would you like to do it?" The CRNA responded that it would be no problem. The CRNA missed that the patient was oxygen-dependent, and he was not given oxygen other than medical air. He arrested and was resuscitated, but he died after being transported to the hospital.

At this facility, a system had developed in which the CRNA didn't come out to get the report, Schilling says. "We're seeing more and more of that in surgery centers," she says. Due to short staff schedules and quick turnover, staff members are becoming totally reliant on paper documentation. Often anesthesia providers will transport the patients themselves without getting the pre-op nurse involved. "That's very risky," Schilling says. "We're seeing all over the country that nurses are not passing off reports to other nurses."

Probably the biggest vulnerability in outpatient surgery is that staff members handle the same procedures over and over again, she says. It's like driving home from work, Schilling says. "You get in your driveway and you ask, 'How did I get here? I don't remember driving,'" she says. "You get into rote and fail to see intricate little pieces."

Conversely, staff may have some procedures that they do only once or twice a year, she says. In those cases, all of the staff members need a dress rehearsal in which they go over the entire process, Schilling says. "Prevention is the thing, having policies, processes, and protocols; educating the staff; and enforcing them," Schilling says.