The following information and recommendations are being shared with all facilities to assist in learning and improving patient safety.
The Non-Hospital Medical and Surgical Facilities Accreditation Program Patient Safety Incident Review Panel recently reviewed an incident involving a patient who required admission to hospital following a procedure at a non-hospital facility. The patient experienced radiating pain, numbness to their left hand and foot, nausea and vomiting, headache, decreased urinary frequency, malaise, euglycemic diabetic ketoacidosis, ileus, acute kidney injury, and scattered subarachnoid hemorrhages on imaging. The patient spent eight days in hospital.
The following contributory factors and observations were considered by the panel:
- The patient’s age and multiple comorbidities – DM, HTN, Crohn’s (controlled), dyslipidemia, moderate obesity, previous TUPR were contributing factors.
- The patient chart was assessed prior to day of surgery and pre-operative medications were ordered. The patient was not asked to attend an in-person consultation.
- The patient stopped taking their DM and HTN medications post-operatively. This is clearly documented in the hospital admission notes. It was unclear what post-operative instructions for restarting medication were given to the patient at the facility.
- Although this patient was elderly, age by itself does not increase the ASA score. Having well-controlled DM and HTN (when taking medications) and controlled Crohn’s also should mean the patient was an ASA 2. However, the combination of age (and hence less physiological reserve) and coming off multiple DM/HTN medications left the patient with a life-threatening complication.
- PONV and poor pain management contributed to the hospital admission.
- It was unclear if there was follow-up with the patient in the first 24 hours or few days post-surgery.
In reviewing the potential impact of the contributory factors on the patient safety incident, the panel made the following recommendations for the facility and others to consider:
- The risk of a reportable event such as readmission post-operatively should be assessed on a case-by-case basis as it cannot be predicted just by looking at the type of surgery or ASA score. This patient could have been identified as higher risk and the facility could have put in place additional measures for follow-up to ensure patient safety and better outcomes.
- Patients identified as high-risk should follow a pre-operative and post-operative protocol (phone calls, home-care visits etc.).
- For high-risk patients undergoing more complex procedures, consideration of the post-operative course should be undertaken by a multidisciplinary team. Social history should be assessed as a part of pre-surgical screening to determine post-operative support requirements for the patient.
Facilities are reminded that care of a surgical patient includes pre-operative assessment to enhance positive outcomes and evaluation of post-operative needs to ensure appropriate recovery.