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

Policy Recommendations

As other states consider action to improve patient safety in the outpatient setting, they should target three broad areas. First, to minimize the number of medical errors that occur as a result of ignorance, office-based physicians must be encouraged to continue to review the current best-practice methods and interact with other physicians so that they are able to maintain and share their knowledge base. Professional organizations should encourage their member physicians to devote time and attention to keeping up with new developments. Conferences and seminars provide forums for physician interaction and are a source of information about current medical developments within a practitioner's specialty. A straightforward electronic and print newsletter, such as the one published by the Department of Veterans Affairs' National Center for Patient Safety, could provide a way for physicians to remain aware of best-practice methods. Informally, physicians practicing alone or in small groups should be encouraged to consult one another and discuss treatment options for difficult cases.

Second, accreditation is a valuable way to ensure the safety of ambulatory surgical facilities and offices where surgical procedures are performed, so we recommend that both types of facilities be required to obtain accreditation from the JCAHO, AAAASF, or AAAHC. Once clinics and surgical centers receive accreditation, they are still under considerable pressure to maintain the standards needed to obtain approval. However, the current system, with varying standards and methods for accreditation, is confusing to patients, physicians, office staffs, and regulators alike.

Instead of having overall facility standards approved for centers that perform very different types of procedures, standards could be created for each specialty. It would be better for anesthesiologists to use the standards described in the various ASA guidelines as benchmarks for providing appropriate care instead of adhering to the anesthesia accrediting standards of the three organizations.[50] Professional societies should consider implementing standards for facilities performing procedures within their field, using the ASA guidelines as a model.

However, the accreditation organizations are useful for ensuring that the sites where office-based procedures are being performed have adequate safeguards. State and federal authorities should encourage office-based facilities to obtain accreditation; one way to do so is to make Medicare and Medicaid reimbursement contingent on obtaining "deemed status," as is the case with hospitals. Accreditation is useful in determining whether the facilities of a physician's office are appropriate and meet the standards necessary to provide safe patient care. The issue of whether the provider is qualified to perform a procedure is a separate issue, best addressed through other means.

Third, the postoperative complications that have occurred during outpatient cosmetic procedures and the elective nature of such surgery mandate that special attention be paid to this area. Standards for length and types of patient monitoring are needed to minimize unnecessary complications from anesthesia. One possibility s to mandate the use of licensed anesthesiologists when major liposuction procedures are performed in office settings. Major could be defined by either the amount of fat the patient wishes to have removed or the expected duration of the procedure. For example, Rhode Island recently implemented regulations on all office-based procedures that place a four-hour time limit on procedures that can be performed in offices without being reported to state regulators.[51] Inadequate training may also be a cause of adverse events in the outpatient setting. While surgery and plastics training that is board certified may not be necessary for all cosmetic procedures, medical professionals whose only training is a thirty-minute video can now market themselves as cosmetic surgeons. Some errors in cosmetic surgery might be averted through consumers' awareness of a physician's level of training; many would likely elect not to have the procedure done with a particular physician.

Up until now, a number of factors have prevented the field from being better regulated. Physicians have been reluctant to criticize members of other specialties for fear of being accused of self-interest and because of the desire for greater profits. This argument is particularly relevant in cosmetic surgery because patients pay directly for most procedures, and insurance companies are not involved. Efforts to regulate the cosmetic surgery industry in Florida have been supported by plastic surgeons but opposed by medical societies, which are dominated by physicians representing other specialties.[52] Reducing the number of errors in cosmetic surgery will demand the involvement of trained plastic and general surgeons to encourage greater restrictions on who can perform these procedures. State or federal regulatory bodies working to develop regulations for cosmetic procedures should enlist the help of professional organizations, particularly the American Society of Plastic Surgery, which already evaluates the safety of various plastic surgery techniques.


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