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The best time to evaluate your protocols, guidelines, and documentation is not when you are served with notice of a malpractice lawsuit, say experts interviewed by Same-Day Surgery. (See "Dos and don’ts when having a deposition," in this issue.) Examine them now, and look at them from the perspective of patients and their attorneys, they say.
If you use clinical pathways or practice guidelines, make sure they are based upon reasonable, scientific data, says Bill Duffy, RN, MJ, CNOR, assistant vice president of perioperative services for Evanston (IL) Northwest Health Care. Also, make sure the guidelines allow flexibility based on the uniqueness of the patient. "Be clear about why you deviate from the guidelines," he says. For example, "obese patients are at greater risk of skin injury than average-sized patients, so you might position them differently."
Be sure all staff members understand the reasons for deviating from the guidelines so it doesn’t seem as if you treated this patient differently for no reason, he explains.
Documentation in the chart doesn’t have to contain a lot of specifics, he says. "A note that the patient stated that her arm was in an uncomfortable position and the position was adjusted, or a note that the doctor was informed of the lab results, without specific numbers, is all that is necessary," he says. Make sure, however, that the notes are legible. "It doesn’t look good for a nurse to be unable to read her own writing on the witness stand," he says.
If you use pre-printed forms in your charts, be sure that sloppy checkmarks don’t create a problem, says Duffy. For example, if you have the box marked "alert" directly above the box marked "unconscious," a sloppy checkmark might cover both boxes, creating doubt in a jury’s mind. To avoid this problem, print opposites side by side rather than on top of each other, he suggests.
Have clear procedures as to how to handle patient belongings, including eyeglasses and contact lenses, says John Romano, JD, partner at Romano, Ericksen, and Cronin in West Palm Beach, FL. He recalls one case in which the facility did not have a procedure that ensures contact lenses were removed. "The patient was in the hospital and underwent extensive surgery," he says. "She was not fully awake for several days, so the staff did not know the lenses were still in her eyes. By that time, the corneas developed ulcers," he says.
Romano points out that while same-day surgery patients are awake much sooner, they still may be disoriented and not realize the lenses are still in the eyes. "Pain medication may keep the patient sleepy enough that he or she would leave the lenses in long enough to cause discomfort and possible injury," he says. For this reason, include removal of contact lenses on any preoperative checklist and make sure they are out of the eyes before anesthesia is administered, he suggests.
Very strict protocols for discharge are also important, says Cronin. "Everyone has a tendency to move on and get the patients home," he says. While this is the business of same-day surgery, it’s critical to be extra careful with a lethargic patient, Cronin emphasizes. "There is a fine line between someone who is resting comfortably and someone who is almost dead," he adds. Be sure to keep the patient long enough to make sure they are not overly lethargic, he says. This point will differ between patients, type of anesthesia, and family support, he says.
Another good practice after discharge is to call the patient’s home several hours after surgery, he adds. Let the patient’s family know that you will be doing this so they won’t be alarmed at the call, he adds.
"Patients and their families won’t call about little things, so before they are discharged, remind them they can call, and make sure they have a telephone number," he says. "Not only does this reassure them that you are still available, but it gives you a chance to identify a potential complication early."