June 12, 2007
Many have asked why all Joint Commission’s patient safety goals should apply to ambulatory surgery sites. After all, the patient is only there for a matter of hours and then goes home. Right? Why should we have to jump through all sorts of hoops for something that really doesn’t pertain to us? We are only here to do this one procedure and what do we know, anyway, about all those other medical problems the patient has.
Well, you have to remember that ambulatory surgery is a part of a larger healthcare continuum and events related to ambulatory surgery can be reflected in other parts of that continuum. Let’s look at an example. Last week we mentioned that medical records are often a problem in ambulatory surgery sites. A patient came to an ambulatory surgery site for a procedure. Very little history had been provided prior to the patient’s arrival so on the day of the procedure staff asked the physician’s office to fax over some relevant office notes and the medication sheet. While hospitals have clearly begun to comply with the “do not use” abbreviation lists, most physician office notes are still replete with such abbreviations. The faxed notes were included in the facility medical record. The surgical procedure went well and the patient went home without incident or complication. However, 2 weeks later she was seen in the ER of the same hospital system for an unrelated problem. The patient’s primary physician was not available. The ER physician found in the patient chart copies of those office records that had been faxed in to the ambulatory surgery site. One of the medications listed in those records had a “qd” abbreviation that, perhaps in part because of fax artifact, looked like “qid”. The patient was admitted from the ER to the hospital and her maintenance medication that had been intended to be given once daily was now actually give four times daily. The error was not discovered until the patient developed symptoms of drug toxicity 5 days later. Well-performed medication reconciliation and compliance with the “do not use” list goal could have prevented this adverse outcome. But the case nicely illustrates how events in one part of the system can effect events in another part.
Medication reconciliation is also critical before and after ambulatory surgery. It is critical that a full list of the patient’s medications, including OTC drugs and herbal remedies, be reviewed before the procedure. Several of these might predispose the patient to bleeding problems, for example. And one especially needs to know when the last dose of medication prior to arrival for the procedure was taken. This is especially relevant for medications such as insulin and ties together with orders for the patient to be “nothing by mouth” for a period prior to surgery. Similarly, it can be anticipated that on discharge from ambulatory surgery the patient is likely to receive some new drugs, for example analgesics and perhaps and antiemetic. One needs to be sure there is not likely to be a drug-drug interaction with the patient’s current medications.
Last week we noted that Joint Commission is finding less than full compliance in ambulatory surgery on several medication-related goals (eg. medication reconciliation, labeling medications and solutions, “do not use” abbreviations, and look-alike/sound-alike drugs). Today’s tip illustrates why at least 2 of those goals are important in ambulatory surgery patient safety. We’ll talk about labeling medications and solutions and look-alike/sound-alike drugs in future tips.