Room for Improvement: Pediatric ambulatory centers could benefit from guidelines, panelists say

Then there are “automatic behavior arrays,” he explained, which can occur when several procedures performed in succession are all the same, leading to the risk of falling into a habit. “It’s a paradigm of thought that you go through when you have seven tonsillectomies, and your eighth case is a tonsillectomy and a tube removal,” Dr. Shah said. “It’s very easy to forget about that.”

Certain error types, identified in a 2004 study in The Laryngoscope that involved an anonymous retrospective survey of 2,500 AAO-HNS members (114(8):1322-1335), specifically apply to ambulatory centers. One is surgical management, which accounted for 61 percent of the errors identified in the study, Dr. Shah said. These are errors that involve things like poor planning and mistakes related to equipment, and they can lead to problems like operating on the wrong side of the body.

“Every time I operate in my surgery center I get a little bit nervous because the pace is fast—it’s built that way—and I don’t help the system when I keep adding on cases,” Dr. Shah said. “But this is a big zone of risk when you talk about wrong patient, wrong organ, wrong side or incomplete surgery.”

That study cited two errors due to “wrong facility.” “These were done at surgery centers, and surgeons wish they would have done them at the main hospital,” Dr. Shah said.

Safe Numbers

Still, a review by the American Association for Accreditation of Ambulatory Surgery Facilities found one unanticipated sequela for every 299 procedures, a rate of just 0.33 percent.

And a 2008 review of 4,977 cases performed at the ambulatory center of the CNMC found only nine unanticipated outcomes, a rate of 0.2 percent.

Overall, Dr. Shah said, “ambulatory surgery is extremely safe within otolaryngology.”

Dr. Shah said safety data allow for benchmarking opportunities. “It allows you folks to go back to your practices, have your administrator run those numbers and give you a rough idea of where you are. If you’re at 5 [or] 6 percent of unanticipated outcomes, it poses a question as to why.”

At the ambulatory center on the Liberty Campus of the Cincinnati Children’s Hospital Medical Center, a review found no unexpected events out of 275 cases at the center, compared to nine unexpected events out of 211 cases at the main hospital, said Dr. Arjmand, the facility director. That facility has the capacity for short-term admissions, but there is limited specialty physician coverage, no emergency surgery is performed and there is no blood bank.