The prevalence of outpatient surgery or ambulatory surgery has increased dramatically globally. Outpatient surgery is a type of surgery in which the patient is discharged within 23 hours (Van Caelenber et al., 2019). Also known as day surgery, outpatient surgery is a cost-effective medical procedure for treating surgical patients. The significant increase in the prevalence of patients with complex medical conditions undergoing day surgical procedures is associated with advancements in non-invasive surgical methods and the availability of regional anesthesia with minimal or zero side effects (Van Caelenber et al., 2019). An efficient and flexible pathway with high-quality nursing care and close monitoring facilitates optimal home-based care for day surgery patients (Van Caelenber et al., 2019). However, ambulatory surgery is associated with undesired health outcomes. First, unanticipated admission among ambulatory surgery patients has recently increased, indicating poor quality and unsafe patient care (Van Caelenber et al., 2019). This trend makes ambulatory surgery less effective since discharging the patient within 23 hours is the primary goal of outpatient surgery. Moreover, the surgical day unit has reported several cases of failure to discharge ambulatory surgery patients on time (Van Caelenber et al., 2019). In some cases, ambulatory patients are temporarily referred to an alternative clinic unit, such as the post-anesthesia care unit (PACU). Prolonged stay in such settings with subsequent discharge on the day of the surgical procedure or even unanticipated overnight hospital stays make a day of surgery costly, making ambulatory surgery lose its cost-saving aspect. Consequently, there is a need to define care safety in ambulatory surgery. This concept paper analyses patient safety in a day surgery.
The Relevance of Patient Safety to the Outpatient Surgery
The dramatic increase in cases ofadverse events in ambulatory medical surgeries remains a significant public safety concern. According to Kuriakose et al. (2022), unsafe ambulatory care results in increased injuries, morbidities, disabilities, or deaths. Approximately 1 in 300 patients are at risk of dying from preventable medical errors while receiving health care in ambulatory or primary care settings (Kuriakose et al., 2022). Moreover, unsafe medical practices result in unnecessary usage of scarce specialist and hospital resources due to higher healthcare usage and substantial economic costs (Kuriakose et al., 2022). Additionally, unsafe care exposes ambulatory surgery patients to increased treatment costs due to prolonged PACU stays, anticipated hospital admission, and additional medical procedures (Kuriakose et al., 2022). Although the most significant percentage of health care delivery is conducted in the ambulatory or outpatient care setting, efforts to improve patient safety in this department are limited. Therefore, mobile surgery units should focus on improving patient safety. Incorporating evidence-based patient safety interventions into the ambulatory care setting’s strategic plans would prevent adverse events and related undesired outcomes, including increased morbidities, prolonged PACU stay, high risk of disability, and costly treatment.
Uses of Patient Safety in the Ambulatory Care Setting
Patient safety is considered one of the most critical aspects of quality healthcare. The incidence of PSPs has increased dramatically in the ambulatory care setting. The most frequent reports in this clinical setting are mobile therapeutic and diagnostic activities, including diagnostic/anamnesis procedures and medication (Geraedts et al., 2020). Patient safety reduces unnecessary harm attributed to healthcare to an acceptable minimum level. Patient safety problems (PSPs) are characterized by two error types (Geraedts et al., 2020). First, PSPs result from the healthcare provider failing to carry out planned action as intended or applying incorrect clinical procedures. Moreover, the anticipated patient safety incidents (PSIs) fail to occur in unnecessary cases of patient harm. Additionally, PSIs consist of adverse events (AEs), which include incidents that expose the patient to harm (Geraedts et al., 2020).
The increased patient safety problems (PSPs) in ambulatory care settings expose outpatient surgery patients to undesired consequences. First, PSPs tell patients about potentially preventable catastrophic events, including wrong-procedure surgeries, wrong-site, retained sponges, overlooked allergies, and unchecked blood transfusions. These events result in unexpected prolonged PACU stay following the ambulatory surgical procedure. AEs are also associated with unplanned hospitalization, resulting in extended hospital stays. Consequently, PSPs increase treatment costs and impose a substantial economic burden on the ambulatory care unit (Geraedts et al., 2020). Thus, the ambulatory care unit should improve patient safety and adopt PSP prevention measures to prevent undesired consequences following outpatient surgeries. For instance, preventing PSPs in ambulatory care will save costs; hence, enormous economic importance. Additionally, decreasing PSPs will result in provider and patient satisfaction.
The Defining Attributes, Antecedents, and Consequences of Patient Safety
The Defining Attributes
Defining attributes are terms that describe the intended concept in the best way. Walker and Avant (2011) describe attributes as ideas that appear repeatedly in one concept. These concepts play a significant role in differentiating various concepts. A single concept is defined by more than one attribute. The defining attributes primarily associated with “Patient safety” include preventing medical errors and avoidable AEs, protecting patients from potential injury or harm, interprofessional team members’ collaborative efforts, and a well-integrated healthcare system.
Prevention of Avoidable AEs and Potential Medical Errors
Medical errors are common in ambulatory care settings. These errors are categorized into commission and omission errors. The commission is characterized by an action taken, while errors of omission are associated with an action not taken. Both errors expose outpatient surgery patients to preventable adverse effects. However, some adverse events, such as postoperative medical complications, might be unavoidable. The patient safety measures focus on reducing the incidence of preventable medical errors and avoidable AEs (Antônio et al. et al., 2023). Thus, ambulatory care settings should adopt strategies for detecting and preventing avoidable medical errors and AEs.
Protecting Patients from Harm
Another patient safety attribute involves protecting patients from potential harm. The risk of patient harm is mitigated via mitigating factors. The factors include circumstances and actions that prevent a particular incident from exposing patients to harm (Panagioti et al., 2019). The interprofessional team should identify factors that contribute to patient harm. These team members should then work with quality improvement (QI) specialists to develop the most effective measures for preventing patient harm within a clinical setting.
Interprofessional Team’s Collaborative Efforts and Well-Integrated Healthcare System
Furthermore, patient safety is achieved through collaborative efforts among interprofessional team members involved in delivering direct or indirect patient care. Additionally, a well-integrated healthcare system supports interprofessional team members’ collaborative efforts. The most frequent adverse events in ambulatory care settings are associated with human error (Naseralallah et al., 2023). The system level is the most common cause of these errors due to system flaws. Thus, direct healthcare providers and the healthcare system must collaborate to prevent medical errors and avoidable AEs by addressing structures and process defects.
Identifying Antecedents
Antecedents are several events that precede the concept occurrence (Walker & Avant, 2011). Interaction between healthcare providers and the environment where the care is delivered is the first antecedent of patient safety. Preventable patient safety issues can only arise following this interaction, which acts as a system of defenses. These components are associated with vulnerabilities, which might overlap, resulting in preventable adverse events. The Swiss Cheese Model of Accident Causation discusses multiple layers of healthcare systems that protect against potential medical errors or patient harm (Wiegmann et al., 2022). Holes or weaknesses arising from a combination of latent and active failures are the most significant contributing risk factors for adverse events in clinical settings. Therefore, a comprehensive patient safety approach targeting active and latent factors should be developed to prevent potential patient harm on various healthcare system layers.
Consequences of Patient Safety
Consequences are incidents resulting from the concept’s occurrence (Walker & Avant, 2011). Patient safety is associated with positive or negative outcomes. Positive outcomes occur following the adoption of programs for improving patient safety in clinical settings. For instance, patient safety measures reduce the likelihood of injury or morbidities, improving health outcomes, quality of life, and well-being. On the other hand, unsafe patient care results in adverse health outcomes. The absence of patient safety measures exposes patients to injury and other health complications, deteriorating their health conditions. Additionally, patients are exposed to complicated health issues that might eventually result in death.
The Relationship between Patient Safety’s Attributes, Antecedents, and Consequences and Actual Ambulatory Care Setting Practice Activities
The defining attributes of patient safety are applicable in the ambulatory care setting. The first defining attribute of this concept involves preventing avoidable medical errors and AEs. Thus, the ambulatory care department’s management should focus on preventing potential preventable PSPs and AEs in this unit. The second attribute involves protecting patients from potential injury or harm. Therefore, the ambulatory care unit’s manager should focus on preventing potential harm and AEs among outpatient surgery patients. The last attribute of patient safety requires the ambulatory department’s interprofessional team members to collaborate through the healthcare system to prevent potential adverse events. Moreover, the antecedent of patient safety, involving interaction between healthcare providers and the environment, can be applied in the ambulatory care setting to prevent potential PSPs and related adverse outcomes. The department management should focus on detecting and amending health system issues that might contribute to PSPs. Lastly, improving patient safety in ambulatory care would result in positive outcomes, including cost-effective treatment.
The Model Case
Mr. D, a 56-year-old male, visited the ambulatory care unit for tonsillectomies. The patient became less stable due to anesthesia administered during the surgical procedure. The patient’s physician instructed the nurse on duty to assist the patient in moving around or getting out of bed to prevent potential patient falls. The nurse frequently checked on the patient for pain, toileting needs, and overall condition. Additionally, the nurse collaborated with the physician, pharmacist, and other interprofessional team members to meet all patient’s needs, including medication and nutrition. In this model case, the nurse immediately protected the patient from potential harm. Actions taken to minimize the risk of errors and avoidable AEs included placing a fall risk sign beside the patient’s bed and assisting him with movement and toileting needs. Thus, the hospital’s fall prevention policies and procedures indicate collaborative efforts among interdisciplinary team members.
Limitations to Use Patient Safety in Ambulatory Care Practice
Two significant contributing factors have compromised efforts to improve patient safety in ambulatory care settings. The first healthcare’s growing complexity jeopardizes efforts to reduce PSPs in the ambulatory care setting. Changes in modern healthcare practices, including the introduction of clinical guidelines and evidence-based practices (EBP), the need for patient-centered care, and coordination among interprofessional during care delivery have led to complexities in healthcare. Dang et al. (2021) reported that interprofessionals have adopted EBP and clinical guidelines to align their practice with current healthcare needs for better and optimal patient outcomes. Thus, developing and adopting initiatives with all these complexities throughout ambulatory surgery patients’ treatment results in patient safety issues, such as medication prescription errors. Secondly, the rate of comorbidities has increased significantly among patients treated in ambulatory care settings. Studies show ambulatory care providers experience challenges in treating patients with comorbidities and multiple social needs (Patel et al., 2020). Therefore, multimorbidity in the ambulatory surgery population predisposes these patients to PSPs.
Conclusion
Patient safety among ambulatory surgery patients is a significant clinical issue that must be addressed. Patient safety issues occur following interaction between the healthcare environment and the providers. PSPs result in undesired outcomes, including prolonged PCU/ hospital stay and costly medical care, imposing a substantial economic burden on an individual patient and the hospital. Importing patient safety would result in cost savings and provider and patient satisfaction. However, efforts to improve patient safety in the ambulatory care setting are compromised by increasing healthcare complexities and a high rate of multimorbidity among ambulatory surgery patients.
References
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