Even patients who seem healthy can die unexpectedly — How will you respond?

A 27-year-old former college football player came in for an elective procedure to relieve hip pain. According to media reports, he hoped the surgery would clear a path for him to audition for a professional football team.1 However, he seized on the operating table and went into cardiac arrest, reports said. Doctors successfully revived him, but he never completely recovered, they said. He later died.

This incident, which happened last spring at a Texas hospital, was followed by press coverage that included interviews with the deceased man's twin brother and his college sweetheart wife, who said a painkilling injection "went wrong."1 The hospital said in its response that he experienced "a rare, but known complication of anesthesia." The family attorney has said a wrongful death suit is likely.1

A death or other sentinel event can happen in any outpatient surgery program at any time. When it does, you need to have policies and procedures in place to handle such incidences.

In ambulatory surgery, providers normally aren't thinking about the fact that they're caring for critically ill patients, says Anne Dean Schilling, RN, BSN, consultant with The ADA Group, a DeLand, FL-based consulting firm specializing in ambulatory surgical development and regulatory compliance. "We're thinking this is an otherwise healthy patient, and we've done 5,000 cases without any problems," she says. "When it does, the shock is unreal."

Here are the steps to follow when a death occurs:

• Show compassion to the family.

Don't be afraid to say, "I'm sorry this happened," Schilling says. You're not accepting blame, she says. "You're showing empathy and compassion for the family and caregivers."

The physician should state the facts but should not elaborate or admit blame, she says. Some states have passed "I'm sorry" laws to assure physicians that they can express sympathy and regret without increasing their liability risk, says Linda Stimmel, JD, partner and cofounder of Stewart & Stimmel in Dallas and a medical malpractice litigator. Most of these new laws are really just a clarification of regular evidence rules to publicize to health care providers that they need not be afraid to show compassion for patients in fear they may become plaintiffs, Stimmel says.

Facilities that have access to a chaplain may want to have that person also talk to the family, says Sheila Mitchell, RN, MS, BSN, CNOR, perioperative nursing specialist at the Center for Nursing Practice for the Association of periOperative Registered Nurses (AORN). Provide a quiet location for the family where they can talk and make phone calls, she suggests.

• Handle notification and documentation.

When a patient dies, don't remove any tubing or drains, says Joan Blanchard, RN, MSS, CNOR, CIC, perioperative nursing specialist at the AORN Center for Nursing Practice. "The patient needs to remain just as they expired until the coroner gets there," Blanchard says. It is permissible to cover the body with a sheet if the family requests to view the deceased, she says. Prepare the family for the body's appearance and explain that the tubings and drains won't be removed until after the coroner arrives, Blanchard says.

Document the facts in the record with no elaboration, Schilling says. Fill out an incident/occurrence report. "There should be no stories or drama, just what they saw," she says. Most states typically require a death report, Schilling adds.

• Address grief of staff.

Pull together members of your staff and the physicians that day to verbalize what they're thinking and feeling, Schilling says. "You don't want to send people out traumatized to their community and home," she says.

Remind staff that federal privacy requirements mean that they can't talk about the incident with family members, Schilling says. Provide grief counseling through a professional counselor, such as a psychologist, sociologist, or social worker, she says. "The staff will be in shock," Schilling says.

Hold follow-up sessions at staff meetings where you encourage them to share feelings, Mitchell advises. You can discuss the grieving process and how staff felt having to handle issues with the family, she says. Blanchard says to keep in mind that staff members may cope very well immediately after the death, but they may have concerns as they work through that situation. In that case, offer further counseling, she suggests.

If you have access to a chaplain's program, review their resources on death before an incident occurs, Mitchell suggests. These resources can prepare staff for what they'll experience with the family, for example, she says. "If they're doing this on a regular basis, whether they experience death in OR or not, at least they'll be prepared for it."

Establish a rapport with a chaplain who could be available to the staff and the family for support if a death occurs, Blanchard advises.

• Critique what happened.

Perform a root-cause analysis to determine the cause of the death, Mitchell says. In fact, a review of the quality of care should start the next working day, Schilling advises.

Determine whether all of the equipment was in good order, whether all of the processes were followed, and whether there was an interruption in processes that could have prevented or changed the outcome, she suggests. "Analyze every step of the process, and figure out where the breakdown was," Schilling says.

Make changes to policies as needed, and get every staff person inserviced, she says.

• Address family issues.

Consider sending the family a card and/or flowers to the funeral, Mitchell says. "Those are communication steps that often, in addition to open communication, have been proven to ease the family over the death of a loved one by showing they care," she says.

Should you bill the family? Yes, Schilling answers. "We would let the lawyers decide later about adjusting in a settlement," she says. Some experts say that if you don't bill the family, you're admitting blame, whether that's true or not, Schilling says. "It's the same as discounting services, which we can't legally do anyway," she adds.


  1. Abrahams T. Aspiring athlete dies after undergoing elective surgery — Family members want answers. Accessed at http://abclocal.go.com.


For more information on handling patient deaths, contact:

  • Joan Blanchard, RN, MSS, CNOR, CIC, and Sheila Mitchell, RN, MS, BSN, CNOR, Center for Nursing Practice, Association of periOperative Registered Nurses (AORN). Phone: (800) 755-2676, ext. 334.
  • Anne Dean Schilling, RN, BSN, Consultant, The ADA Group, 911 E. Minnesota Ave., DeLand, FL 32724. Phone: (386) 956-1817 and (386) 736-6202. .E-mail: ADean9@cfl.rr.com or Anne@TheADAGroup.com. Web: www.theadagroup.com.