Don't let these areas of patient safety slip
The admitting nurse has finished the paperwork. The anesthesiologist has started the IV. The surgeon is there, anxious to begin. Everyone is standing behind you, waiting for you to finish preparing the patient. The "little" things, like remembering to pull up the side rails and checking for allergies, start to slip through the cracks.
"In ambulatory surgery, we're in a rush. It's a rush activity from start to finish," says Shauna Smith, RN, CAPA, compliance coordinator at Idaho Falls (ID) Surgical Center. "You tend not to listen to patient concerns or anxiety."
Sometimes this rush can have disastrous results. Consider an acquaintance of Smith's who had outpatient foot surgery at another facility. Four months after the operation on one foot, she had it performed on the other foot. "After surgery, she felt dizzy and lightheaded and slightly disoriented," Smith says. "She kept trying to tell the nurse that something was wrong."
The nurse responded that it was merely a normal side effect of the anesthesia, and the patient was sent home. "She was transported by ambulance back to the hospital because she went into respiratory failure," Smith says. The physicians don't know what brought about the condition, but the patient knew something was wrong, Smith emphasizes. "We have to be careful to listen to patients and pay attention to what they tell us and be willing to let their stay be extended by some time if necessary."
Ignoring patient complaints isn't the only potential problem area for rushed same-day surgery programs. (See above story about a new campaign to address operative site identification.) Consider these other areas:
o Pre-op testing/information.
Under managed care, many outpatient surgery procedures are using local anesthetics. The danger is that the staff may not perform as in-depth testing and documentation with local anesthesia, and they may be unaware of patient allergies or other problems, says Malcolm (Duffy) Parsons, ARM, vice president of risk management at Doctors Hospital and president of the Network of Risk Management Consultants, both in Columbus, OH.
Don't just collect data; read them, he emphasizes. Bring abnormal or borderline results to the attention of the anesthesia providers or the surgeon. "Are the lab values within normal limits? Is there anything on the EKG of concern to the doctor or anesthesiologist?" he asks.
o Patient identification.
Develop a system for ensuring the correct patient gets to the correct OR, Smith advises. Make the patients tell you their names, she suggests. To avoid creating fear or the impression that you're incompetent, be warm and friendly. For example, you can say, "Mrs. . . ." and pause. "They'll fill in the blank," she says. Or say, "I know you've been asked this before, but I'm asking it again because we want to be very careful."
o Documentation.
In same-day surgery, all the paperwork has to be complete and accurate, just as in any other medical setting, Smith emphasizes. "But we're given less time to do that, and so checklists and scoring systems have helped streamline the documentation. But again, you have to go back to basic nursing judgment - document what you see."
Checklists can help ensure you're in compliance with hospital policies, state laws, patients' rights, informed consent, and preoperative testing guidelines, Parsons says. (See pp. 118-119.)
Consent forms are a specific problem area because they often are too narrow, he says. He recounts the story of a recent patient who was having a laparoscopic cholecystectomy. "The surgeons got in there and had to change the surgery because they couldn't get it done with a laparoscope. The appendix was inflamed, and they had to remove it." Unfortunately, the consent form didn't include consent for an open cholecystectomy or removal of the appendix. Luckily, the patient had a good outcome. "But if the patient had a bad outcome, he might have said, 'You had consent for one procedure, and while I was under anesthesia, you changed the method. You didn't communicate that to me or my family.'"
Use a consent form broad enough to allow latitude for the surgical team if it encounters problems, Parsons advises. (See p. 120.) "In essence, we say we have the latitude to fix the problem, if it's not fully isolated preoperatively," he says.
Another trouble area is getting physicians to put history and physicals (H&Ps) on the chart before surgery. (For tips on getting your physicians to put H&Ps on the chart, see Same-Day Surgery, June 1997, p. 76. For information on standards from the Joint Commission on Accreditation of Healthcare Organizations, see story, p. 123.)
Many same-day surgery programs are moving toward performance credentialing to address such problems, Parsons says. Under this system, a physician's outcomes and behavior are factors in the credentialing process. Advise the supervisors of the physician credentialing process of any problems you encounter with physician documentation, Parsons advises. "If it's not communicated, you wind up having to put up with it," he says. "That's not in the best interest of the patient, and that's why we're here."
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