Survey draws attention to outpatient surgery errors: Is your program at risk?

We list the areas where you most likely could threaten safety

A 7-year-old goes in for routine ear surgery and dies after receiving a dose of concentrated epinephrine. Hundreds hear the story at a national conference, and hundreds more view a video presentation.1

Surely this is an isolated case — or is it?

A recent survey of safety errors in otorhinolaryngology practice shows that of 466 responses, there were five cases of inadvertent injection or placement of 1:1,000 epinephrine.2

"It is very possible that this practice continues because too many good clinicians believe It won’t happen to me,’" says Waldene K. Drake, RN, MBA, vice president of risk management at Cooperative of American Physicians-Mutual Protection Trust in Los Angeles. Clinicians fail to realize how many factors can intersect to cause an error, even when good people are dedicated to patient safety, Drake says.

David W. Roberson, MD, assistant professor of otolaryngology at Harvard Medical School in Cambridge, MA, and an associate in the department of otolaryngology and communication disorders at Children’s Hospital Boston, says, "An RN in the OR has a thousand things going on, and nothing could be easier than to get distracted and forget to dilute the epi. Or lunch relief could come in, and the task could fall between the cracks."

Patient safety errors are made by physicians, nurses, and other clinicians; and now they are receiving significant national attention. The Senate recently passed the Patient Safety and Quality Improvement Act, which allows health care errors and serious events to be reported voluntarily and confidentially, without the threat of legal repercussions. The Senate bill must be reconciled with a bill passed by the House earlier this year.

In the meantime, practitioners can learn from the report on common areas of medical errors published by Roberson and his co-authors in the August issue of The Laryngoscope.

Although the study specifically targeted otolaryngology, most of the errors and the suggestions to prevent them apply to outpatient surgery in general, say sources interviewed by Same-Day Surgery.

One of the top 10 safety tips given by the authors is to eliminate concentrated epinephrine from the surgical field.

"It should not be just one of the many tasks the nurse has to do as she sets up the case," Roberson says. Options include using lidocaine with epinephrine or having a pharmacy premix syringes, he suggests. If elimination isn’t feasible, two people can watch the nurse dilute the epinephrine, adds Roberson.

The danger of patient safety errors definitely exists in an outpatient surgery setting, notes Stephen Trosty, JD, MHA, CPHRM, director of risk management and continuing medical education at American Physicians Assurance Corp. in East Lansing, MI.

"The more hurried, the more rushed, the more stressed the person doing the preparation and administration of monitored anesthesia care [MAC] might be, the greater is the potential for error," says Trosty, who bases his comments on his risk management and claims experience. 

Lessons for outpatient surgery

In their study, Roberson and his co-authors identified specific areas where providers reported errors. They include:

  • Communication errors.

To avoid communication problems, informed consent should not be obtained on the morning of surgery as the patient is going in for a procedure, Trosty maintains.

Verify that those who are performing the surgery and anesthesia have obtained appropriate consent, he adds. Without it, "you can end up with malpractice," Trosty explains.

The patient should be a partner in the decision-making process, he advises. The discussion should include the medical problem, potential risks and benefits of the procedure, any alternative treatments, and an explanation of the surgery. "Patients may have strong feelings," Trosty says. "Those should be appropriately documented."

  • Incomplete or incorrect history and physical (H&P).

Allergic reactions can be very common in outpatient surgery, Trosty points out. "It becomes very critical, before any surgery is done, that a thorough H&P with emphasis on any known allergies is taken," he says.

Trosty recommends that if a patient has a known allergy, a red label should be placed on the front of the patient’s chart. "If it’s buried in the record, it will be much easier to miss," he says.

Also, determine what medications the patient is taking and ensure that any medications, which can exacerbate the effect of anesthesia such as blood thinners or beta-blockers, have been discontinued, Trosty advises.

Blood thinners can create a bleeding problem, and beta-blockers may indicate a need for closer monitoring, he says. "These have caused malpractice claims in outpatient surgery," Trosty adds.

Additionally, patients should be asked about herbal medications, over-the-counter medications, and recreational drug use, sources say.

  • Surgical planning and judgment errors.

The preoperative evaluation must include evaluation of the level of skill and care that the patient and procedure will require, Drake emphasizes.

"This means that a high-risk patient may not safely undergo a procedure in an outpatient setting if he needs the backup availability of a full range of emergency services that only a hospital setting can provide," she says.

Outpatient surgery centers that are owned by physicians or a physician group must take extra strides to ensure this evaluation is carried out objectively, Drake says.

  • Medication errors.

The Joint Commission on Accreditation of Healthcare Organization’s new 2005 National Patient Safety Goals include a requirement that all providers identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization and take action to prevent errors involving the interchange of these drugs.

Medication errors are frequent in outpatient surgery, says Lori Bartholomew, director of research at Physician Insurers Association of America in Rockville, MD.

Two potential factors are that staff members might not be accustomed to working together daily, and there might not be a pharmacy on site, she says.

Providers need to double-check medications with visual confirmation of the dosage and the particular drug, Bartholomew notes.

The danger in the outpatient surgical setting is being lulled into complacency because things go so well so much of the time, Roberson says. "Keeping a high alert level for things that are very rare is hard for most normal humans," he adds.

In outpatient surgery, the volume is such that you may go 10-30 years between major safety errors, Roberson warns. "You can’t rely on your own experience," he advises.


1. Leape LL. Errors are not diseases: They are symptoms of diseases. Laryngoscope 2004; 114:1,320-1,321.

2. Shah RK, Kentala E, Healy GB, et al. Classification and consequences of errors in otolaryngology. Laryngoscope 2004; 114:1,322-1,335.


For more information on improving risk management in outpatient surgery, contact:

  • Lori Bartholomew, Director of Research, Physician Insurers Association of America, 2275 Research Blvd., Suite 250, Rockville, MD 20850. Phone: (301) 947-9000. Fax: (301) 947-9090. E-mail:
  • Waldene K. Drake, RN, MBA, Vice President, Risk Management, Cooperative of American Physicians-Mutual Protection Trust, 333 S. Hope St., Eighth Floor, Los Angeles, CA 90621.
  • David W. Roberson, MD, Associate, Department of Otolaryngology and Communication Disorders, Children’s Hospital Boston, Fegan 9, Boston, MA 02115.
  • Stephen Trosty, JD, MHA, CPHRM, Director, Risk Management and CME, American Physicians Assurance Corp., East Lansing, MI. Phone: (800) 748-0465, ext. 6808 or (517) 324-6808. Fax: (517) 332-0262. E-mail: