ASC Adviser

Patient Safety Issues: A Re-Examination

Protocols and procedures for a safe ASC require frequent review and evaluation.

By Brad Black, M.D.

We have always considered patient safety in our Accreditation Association for Ambulatory Health Care (AAAHC)-certified ambulatory surgical center (ASC) far better than sufficient. So, one might imagine the shock we experienced when our director of nursing received a call from the ER informing us that an elderly patient who had been discharged 2 hours prior following successful cataract surgery, was now being heli-vaked to the ER with a head injury. The nurse then shared with us that this was the third occasion in recent months where patients had been admitted to their ER with a similar accident after routine cataract surgery.

The patient in question had received mild sedation, a peribulbar block and routine cataract surgery. After the proper paperwork was signed, she drank a soda in the postoperative area, was escorted in a wheelchair to a car and released to the care of her son-in-law. He drove her home, walked her to the front stairs, and then returned to his car, leaving his mother-in-law unattended on the stairs to retrieve her purse. When the son-in-law returned, our patient was laying at the bottom of the steps unresponsive.

The question begs, what if we had not escorted the patient to her car and she had fallen on the pavement in our parking lot? There may have been a legal nightmare had the patient's caregiver not signed and acknowledged that he understood his mother-in-law had received sedation and that she needed assistance for the next several hours. Even worse, what if our patient had been anticoagulated on coumadin and then sustained a life-threatening epidural hemorrhage?

The purpose of this article is not to debate the selection of preferred anesthesia during cataract surgery and the risks and benefits thereof. In fact, we strongly favor peribulbar blocks rather than topical anesthesia for all routine cataract surgeries. The purpose of this discussion is to share what changes have occurred in our facility since the above incident occurred and caused us to re-examine patient safety issues in our own facility.

Targeting Areas In Need of Improvement

While it would be a daunting task to delineate every patient-safety issue, the instrumental change for us came from using the "German Engineering" method as our model; i.e., we began a continuous improvement process (CIP). A group that consists of one nurse from each area in our ASC (preop, intraop, postop and anesthesia) meets bimonthly to discuss potential problem areas in our facility (e.g., the electricity goes out and the generator will not start). This CIP team helps not only to better prepare us for the unplanned and unexpected, but also to avoid that worst case scenario.

The Outpatient Ophthalmic Surgery Society (OOSS) is a professional medical organization that provides advocacy, education and practice management support to the nation's ophthalmic ASCs. For more information about OOSS, contact Claudia A. McDougal, executive director, at 866-892-1001 or visit www.ooss.org.

Here are some examples garnered from those meetings:

Preventing patient movement during surgery

► 85% of patients do not receive an IV in favor of sublingual midazolam (administered with mint). There is a slower onset of action, yet lighter sedation with less "startle"

► We establish IV access in patients only with a cardiac history (arrhythmia, CAD, previous MI), patients "at risk" high blood pressure, labile diabetes, or patients w/elevated levels of anxiety, if we fear they might move

► 95% of patients receive a peribulbar block (2% xylocaine and Vitrase (ISTA Pharmaceuticals) in a 10-cc syringe with a 25-gauge, 1.5 inch needle). We believe this helps in greatly reducing surgical complications to a rate that approaches one in several thousand. Topical Tetravisc (OcuSoft) in the fornix and "diversion" assist with comfort during this "transconjuctival" injection

► Patients are positioned comfortably with a vacuum-pack headrest. Their heads are then taped for added security in case of a sudden cough or sneeze.

Preventing incorrect IOL implantation

► Correct patient data entry is emphasized and ID bracelets are double-checked by nurses in each area. Patients, if able, recite their full name and date of birth each time they are asked

► A standardized three-step "time-out" is performed before each case (operative site is marked over the brow with ink skin marker either by the patient or with the patient pointing to the correct eye)

► Accurate IOL calculations are confirmed by the physician as well as preop and OR nurses

► A "cheat sheet" identifying correct eye and IOL are posted at the end of each patient stretcher in a position visible to the surgeon to further reduce chance of human error(s).

Preventing TASS or infection

► Disposable tubing is always used along with the careful monitoring of instrument "life cycles"

► Handpieces are both manually and mechanically flushed after each case. The QuickRinse Automated Instrument Rinsing System (American Optisurgical Inc., Lake Forest, Calif.) works wonderfully

► Following sterilization, the indicator checks and printout are placed on the chart. A patient label is placed on the autoclave printout before being attached to the OR record.

Preventing "Medical Instability"

► Medical and contact allergies are checked and re-rechecked (e.g., Latex)

► Surgery is delayed in patients with marked elevation in blood pressure or blood sugar levels >400. Values above 300 are evaluated on a case-by-case basis

► At the behest of our director of nursing, all nurses and doctors are required to undergo Advanced Cardiac Life Support training. Of note, we were amazed at how much we learned and were embarrassed that time and egos prevented us from doing this much sooner.

Preventing patient falls following procedure

► Patients never walk unattended and are taken to their cars via wheelchair

► Patients are discharged to a responsible adult driver who in turn signs for knowledge of the patient's sedation

► Door-to-door transportation service is available to all patients

► All patients receive a postop telephone call from their surgeon on the night of surgery in addition to a call the next morning from a postop nurse.

Thinking Proactively

We have found that these CIP meetings have not only created ownership amongst our staff in the "quest for improvement" but also have them thinking proactively. Additionally, our patient who wound up in the ER after her first cataract surgery has since been scheduled for surgery on her second eye. I can attest that the entire staff feels better knowing that we've improved our safety protocol. OM