Preventing Errors In The Outpatient Setting: A Tale of Three States

Elizabeth M. Lapetina and Elizabeth M. Armstrong


Health Affairs. 2002;21(4) 

In This Article

Sources of Risk in the Outpatient Setting

Several characteristics of the outpatient setting pose potential risks. These fall into two groups, one having to do with the outpatient setting itself and the other, with the actors in that setting. With respect to the setting, the greatest source of risk is inadequate facilities, either to perform the procedures themselves or to deal with an emergency or crisis if it arises. A related problem is that of outdated or inadequately maintained equipment.

With respect to the actors, the relative isolation of the solo practitioner, the lack of peer review, and insufficient training and experience with the procedures being performed all contribute to the risk environment of outpatient surgery. In office-based medicine, particularly cosmetic surgery, the hospital-based process of peer review, which enables colleagues to judge competence, skill, and readiness to perform procedures, is missing. As a result, physicians without a great deal of experience or training may perform cosmetic surgery, sometimes after attending only a weekend seminar or watching a thirty-minute video. Even if physicians are well trained and experienced in the performance of procedures, they may lack training or experience in crisis response, particularly in resuscitation. Moreover, physicians practicing in an office-based setting do not have the level of contact with other physicians that those working in hospitals have. Consequently, it is harder for them to keep abreast of new medical developments and remember all of their training. Finally, physicians in office-based settings are frequently operating without an anesthesiologist or anesthetist in attendance.

Indeed, as the studies by Rama Rao and Charles Coté demonstrate, anesthesia appears to pose a particular risk in the outpatient setting.[16] When persons without adequate experience or equipment administer anesthesia, there can be devastating consequences that are difficult to correct in an office setting. Patients may suffer from malignant hyperthermia, a rare reaction to anesthesia drugs that causes the body to overheat.[17] It can be corrected with dantrolene, an expensive drug that many office practices simply do not stock. Young children are easily susceptible to becoming over-sedated during procedures. Children may stop breathing while sedated and can die if not properly monitored. Office-based practices typically do not measure the oxygen levels of their patients or have crash carts, cabinets on wheels that contain resuscitation and emergency therapeutic medication that are standard equipment in the hospital. Despite clear recommendations from the American Society of Anesthesiologists (ASA) on the use of pulse oximetry (which measures blood levels of oxygen), it does not appear to be used consistently in outpatient settings.[18]


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