SDS Accreditation Update: Delays, postoperative complications rank high in percentage of sentinel events
SDS Accreditation Update
Delays, postoperative complications rank high in percentage of sentinel events
Joint Commission looks at reasons and recommendations for prevention
Although outpatient surgery managers often focus on avoiding wrong-site surgery, they should be equally concerned about delays in treatment and operative/post-op complications, which together cause sentinel events that are reported more often than wrong-site surgery.
Wrong-site surgery leads the list of sentinel events recorded by the Joint Commission on Accreditation of Health Care Organizations for freestanding ambulatory care organizations since January 2001, with 32.5% of reported events related to wrong-site surgery. However, delay in treatment (19.5% of reported events) and operative/post-op complication (15.6% of reported events) occur frequently enough that outpatient surgery programs should pay close attention, says Richard Croteau, MD, executive director for patient safety initiatives for the Joint Commission.
These statistics reflect only the cases reported voluntarily to the Joint Commission, but there are various states that mandate reporting of sentinel events, Croteau points out. Even though the states’ programs are mandatory, there is never 100% reporting, he adds. However, state statistics can give an outpatient surgery manager another source of information with which to evaluate their program.
"The Joint Commission is working with a number of states to help develop their reporting systems, and we are working toward a system of sharing information," he says. There are a number of issues related to privacy and comparison of data that will make this effort a long-term project, he adds.
Although more than half of the sentinel events related to delays in treatment were reported to the Joint Commission by emergency departments, outpatient surgery programs did report delays in treatment as causes for sentinel events, says Croteau.
"In a surgery setting, a delay in treatment that would result in a sentinel event is most likely a delay in diagnosing and treating a condition such as a venous thrombosis that creates a complication after surgery," he explains.
Other reasons for delayed treatment include delayed test results (15%), physician availability (13%), delayed administration of ordered care (13%), and patient left unattended (4%). "There were multiple root causes for the delays in treatment, but most organizations [84%] cited a breakdown in communications between physicians and staff as a key root cause," Croteau adds.
Incomplete communications is identified as a root cause of operative/postoperative complications by two-thirds of the organizations who reported sentinel events in this category.
Communication breakdowns are key reasons for sentinel events, he adds. This is one area addressed by the Joint Commission’s 2006 National Patient Safety Goal that requires outpatient surgery programs to develop a standard process to ensure communication as a patient moves from one area of care to another, he says.
As more outpatient surgery programs develop handoff communications protocols, the root causes of some of these sentinel events will be addressed, explains Croteau.
A trifold document used by the staff at River View Surgery Center in Lancaster, OH ensures communication between staff members as the patient moves from one area to another, says Patti Moore, RN, director of the center.
"This document is used when the pre-admission nurse makes her first call to the patient to gather information over the phone," she says.
Because the pre-admission call is made 24-72 hours prior to surgery, the nurse is able to pass along any information to the anesthesiologist and pre-op nurse well ahead of the day of surgery so that potential problems, such as an illness or a medication, that might delay surgery can be identified in time to reschedule without disrupting the center’s schedule. "In addition to the pre-admission call, we also call patients the day before their surgery to verify the information obtained in the pre-admission call and to go over any pre-op instructions and information such as arrival time," Moore adds.
"This form has sections for each staff member who will care for the patient to complete," says Moore.
Always a chance to ask questions’
As the patient moves from one area to another, staff members not only give a verbal report of the patient’s condition and care, but they also refer to the written notes on the form, she adds. Because each staff member signs and dates notes made in the document, if there are questions for someone other than the staff member directly transferring the patient, nurses know who to contact if the notes are not clear. "There is always a chance to ask questions if someone has them," she explains.
The operative/postoperative category includes a jumble of complications and procedures, but there are several procedures that are routinely performed in an outpatient surgery setting that resulted in complications, says Croteau. The types of procedure and complication involved in the sentinel events include: massive fluid overload from absorption of irrigation fluids during gynecological procedures, endoscopic procedures that resulted in perforation of adjacent organs, and burns from electrocautery.
In addition to breakdown in communications, other reasons cited by organizations filing sentinel events related to operative/post-op complications include incomplete preoperative assessment, deficiencies in credentialing and privileging, inconsistent postoperative monitoring, and failure to question inappropriate orders.
Standardization of orders is one way that River View Surgery Center staff has addressed communication between physicians and staff members. They developed templates for their history and physicals, pre-surgical orders, operative records, discharge forms, and post-op instructions, says Moore. "The physician simply points and clicks on the appropriate information for the patient, and the information is printed out for the chart and for the patient," she says. "By making the forms and the information consistent, staff members don’t have to ask physicians what they meant by a vague order, and they don’t have to make assumptions as to what the physician intended."
Sources/Resource
For more information about sentinel events, contact:
- Richard Croteau, MD, Executive Director, Patient Safety Initiatives, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd, Oakbrook Terrace, IL 60181. Phone: (630) 792-5776. Fax: (630) 792-5005. E-mail: [email protected].
- Patti Moore, RN, Director, River View Surgery Center, 2401 N. Columbus St., Lancaster, OH 43130. Phone: (740) 681-2700. E-mail: [email protected].
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