Cases & Commentaries
Raise the Bar
A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The patient was seen and evaluated by an anesthesiologist who was new to the center. After discussing anesthetic options with the patient, the physician proceeded with regional anesthesia and performed a right iliac block in the preoperative holding area. The patient was then taken to the operating room, where he awaited the arrival of the surgeon. Without alerting the nurse, the patient tried to get up to use the restroom, but—because his leg was now numb—fell and hit his head on the ground. After hearing the fall, the nurse came quickly to evaluate and, given complaints of acute neck pain, the patient was transferred to the local emergency room. A heated interaction ensued between the anesthesiologist and nurse around why certain safety measures hadn't been taken to protect the patient. Ultimately, the patient didn't experience any significant injury and he had his lipoma removed the following week.
The quality review committee at the ambulatory surgery center investigated the events. It was noted that the rails of the patient's bed were not raised after the block was placed, largely because the nurses were unaware that the procedure had been performed by the anesthesiologist. Because of this poor communication, the nurse assumed that the block would be placed in the operating room (as was done by other anesthesiologists on staff). Moreover, she reported being unfamiliar with the use of regional blocks in general.
Approximately 80% of surgeries are performed in outpatient settings.(1) The move from hospital-based to ambulatory surgical venues has been driven by improved efficiency, reduced cost, and convenience. The transition has also been facilitated by increased safety from surgical, anesthetic, and monitoring advancements as well as improved pharmokinetics of anesthetic and analgesic agents.(2)
Regional anesthetic nerve blocks are commonly used in outpatient settings.(3,4) Advantages include specificity to site, low adverse-effect profile, and excellent surgical anesthesia and postoperative analgesia.(2,3) Fall rates following nerve blocks range from 0.6% to 2.7% and are associated with advanced age, female gender, obesity, and mobilization without assistance.(4) Temporary loss of muscle control reduces proprioception, decreases leg stiffness, and causes lateral instability. All of this makes foot placement, pivoting, balance correction, and fall recovery more difficult.(5) Though relatively uncommon, falls expose patients to potentially preventable injury and can lead to costly medical-legal actions. A number of interventions have been shown to reduce falls in the perianesthesia setting. They include teaching patients not get up without assistance, using stabilizing devices for ambulation, visual cues and communication strategies to highlight patients at risk, and employing bed alarms to warn of patient movement.(5-7)
This case provides an opportunity to discuss the unique aspects of perianesthesia nursing practice as it relates to patient safety. These include knowledge and competency, clarity of role and responsibilities, handoff communication, and patient safety culture stewardship.
Nurse Knowledge and Competency
Nurses in the perianesthesia areas are responsible for ensuring patient safety by assessing and monitoring physiologic status, completing a pre-procedure check-in process, assuring availability and operation of emergency equipment, and administering moderate sedation. Nurses might also be involved in preanesthetic site verification, site marking, and a time out to assure the anesthetic is administered to the right person, for the right procedure, and to the right site.(8)
Professional societies have created standards for the knowledge and skills required of specialty nurses. Nurses working in the perianesthesia area should be competent in ACLS/PALS [advanced cardiac life support/pediatric advanced life support], pharmacology of sedatives and local anesthetic agents (including therapeutic and adverse effects along with recognition and management of toxicity), and neurovascular/neurological assessment. They should also be familiar with the therapeutic and adverse effects of neural blocks.(9) The nurse in this case appeared unaware of what precautions to take when managing a patient with a regional block, indicating a breakdown in training, orientation, or professionalism. If she were new to the specialty, her orientation would involve didactic and skills training including specific perianesthesia safety procedures. Experienced perianesthesia nurses would be expected to have these skills already, but are typically oriented to institutional policies, procedures, and departmental practices with competency validation and training to supplement identified competency gaps. Nurses' involvement in delivery of regional nerve blocks is dependent on Nurse Practice Act stipulations and/or institutional procedures credentialed by the medical board.
Nurses, like all professionals, are responsible for assessing their learning needs and performance requirements, obtaining necessary education, and declining or asking for help with assignments that are truly outside their competencies. This case, which illustrates the interdependence of institutional and individual responsibility for safety, also highlights the fact that it is sometimes difficult to determine the level(s) at which a breakdown occurred.
Roles and Responsibilities
It appears in this case the anesthesiologist administered the nerve block unassisted. Case reviews of errors associated with nerve blocks have recommended multidisciplinary participation in completing the preanesthesia check, the time out, and communicating the risk of falls to the patient.(6,10) Collaborative work increases the likelihood of communication and the creation of shared mental models during care delivery.
Once a patient is anesthetized, procedures should be clear about who maintains patient custody. Nurses care for multiple patients and are responsible for preparing the operating suite. Responsibilities in ambulatory settings are often executed with fewer people than in inpatient operating rooms (ORs). In some settings, nurses in the preoperative or holding areas are not the same individuals who assist in the OR. Dropping off and leaving patients unattended—and without fall precautions—is a safety risk and can disrupt the nurse's workflow, which can result in distraction and delays that increase the potential for subsequent errors.
It is unclear whether a handoff occurred between the anesthesiologist and the nurses in the perianesthesia suite. During a perioperative stay, patient care often is transferred quickly between multiple people, creating the potential for gaps in information. Handoffs between clinicians in the OR are often informal, brief, unstructured, and conducted while performing other tasks.(11,12) In ambulatory settings, patients are typically less acute, less complex, more awake, and more independent than in inpatient settings. Procedures are fast-paced and viewed as routine. These conditions promote abbreviated communication, assumptions about information, and potential bias regarding patient risk or the need for surveillance. Creating standards requiring that handoffs be structured, focused events would likely improve process reliability and information exchange.(13)
Culture of Safety Stewardship
Teams in perianesthesia are often ad hoc and fluid, such that individuals can be unfamiliar with unit norms and colleagues' skills and knowledge. Leaving the orientation of new clinicians to cursory on-the-job guidance by nurses or physicians within the area is insufficient. Credentialing, competency assessment, clear role delineation, and standardized protocols should be provided by someone responsible for ensuring systematic orientation. A more robust safety-oriented review of this event might have included deeper attention to analysis of how workflow processes and systems could be more effectively standardized, mechanisms for improving communication and increasing situational awareness (e.g., implementing visual cues: Figure 1 and Figure 2), and developing methods for individual and cross-monitoring of work.(14) Though not articulated in this case, power relationships, hierarchy, and privileged status can hinder communication and teamwork in the perioperative arena (15) and are well-known contributors to medical error. Flattening hierarchies and encouraging inclusivity, mutual respect, and engagement are central to promoting safety stewardship.
- Fall rates following nerve blocks range from 0.6% to 2.7% and are associated with advanced age, female gender, obesity, and mobilization without assistance.
- Fall prevention strategies in perianesthesia include teaching patients about precautions, bed alarms, and use of stabilizing devices for ambulation, visual cues, and communication to raise awareness of patients at risk.
- Safety measures in ambulatory surgery should include checks on competency; clear procedures, roles, and responsibilities for handoff; and handover of patient custody following anesthesia.
- Increasing safety stewardship requires a culture that discourages behaviors based on hierarchy and consistently encourages all team members to take active responsibility for maintaining safety.
Jim Stotts, RN, MS, CNS Patient Safety Manager Patient Safety and Quality Services University of California, San Francisco Medical Center Assistant Clinical Professor Department of Physiological Nursing University of California, San Francisco School of Nursing San Francisco, CA
Audrey Lyndon, PhD, RNC Associate Professor Department of Family Health Care Nursing UCSF School of Nursing San Francisco, CA
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Figure 1. Patient-Oriented Signage.
Figure 2. Patient Risk Signage.