Patient Safety First in Plastic Surgery
2004; Lippincott Williams & Wilkins; Volume: 114; Issue: 1 Linguagem: Inglês
10.1097/00006534-200407000-00036
ISSN1529-4242
Autores Tópico(s)Medical Malpractice and Liability Issues
ResumoBe great in act, as you have been in thought. —William Shakespeare Patient safety has always been the priority of plastic surgeons and all the organizations that represent plastic surgeons. Many initiatives have been generated to ensure that patient safety remains the priority among our ranks, especially in the two largest organizations, the American Society of Plastic Surgeons (ASPS) and the American Society for Aesthetic Plastic Surgery, Inc. (ASAPS). In light of plastic surgery–related patient deaths in Florida and New York, negative tension about patient safety has risen again. It is even more important that plastic surgeons highlight patient safety initiatives. We must continue to be physicians first, always putting patient safety first. Safety remains the number one priority for the ASPS and has been a major component of the ongoing strategic plan. The ASPS created a patient safety task force that has developed and issued multiple advisories to members on safety in office-based surgery. The ASPS, in conjunction with the ASAPS, has mandated that its members who perform surgery under anesthesia other than minor local anesthesia must do so in a facility that meets one of the following criteria 1: • Accredited by a national or state-recognized accrediting agency/organization, such as the American Association for Accreditation of Ambulatory Surgery Facilities, the Accreditation Association for Ambulatory Health Care, or the Joint Commission on Accreditation of Healthcare Organizations. • Certified to participate in the Medicare program under Title XVIII. • Licensed by the state in which the facility is located. The ASPS has also published multiple articles and advisories on general patient safety in the Journal: • Iverson, R. E., and the ASPS Task Force on Patient Safety in Office-based Surgery Facilities. Patient safety in office-based surgery facilities: I. Procedures in the office-based surgery setting. Plast Reconstr. Surg. 110: 1337, 2002. • Iverson, R. E., Lynch, D. J., and the ASPS Task Force on Patient Safety in Office-based Surgery Facilities. Patient safety in office-based surgery facilities: II. Patient selection. Plast. Reconstr. Surg. 110: 1785, 2002. • Bitar, G., Mullis, W., Jacobs, W., et al. Safety and efficacy of office-based surgery with monitored anesthesia care/sedation in 4778 consecutive plastic surgery procedures. Plast. Reconstr. Surg. 111: 157, 2003. • Byrd, H. S., Barton, F. E., Orenstein, H. H., et al. Safety and efficacy in an accredited outpatient plastic surgery facility: A review of 5316 consecutive cases. Plast. Reconstr. Surg. 112: 636, 2003. • Hasen, K. V., Samartzis, D., Casas, L. A., and Mustoe, T. A. An outcome study comparing intravenous sedation with midazolam/ fentanyl (conscious sedation) versus propofol infusion (deep sedation) for aesthetic surgery. Plast. Reconstr. Surg. 112: 1683, 2003. Upcoming articles scheduled for 2004 include the following: • An ASPS Committee on Patient Safety Practice Advisory on Liposuction, by Dr. Iverson and colleagues. • Outcome of Abdominoplasty Performed under Conscious Sedation: Six-Year Experience in 153 Consecutive Cases, by Mustoe et al. • Long-Term Health Status of Danish Women with Silicone Breast Implants, by Breiting et al. (in this issue:Plast. Reconstr. Surg. 114: 217, 2004). Advisories on pain management and postoperative nausea will also be published in the Journal in 2004/2005. The ASPS has been active in supporting the Patient Safety and Quality Improvement Act and House Bill 663 to enable surgeons and other healthcare personnel to learn why medical errors and adverse events occur, so the necessary steps can be taken to prevent them in the future. In an effort to step up this process, the ASPS has been proactive in formulating a three-point initiative that will accomplish these goals 2: • We will collate a forum of nationally recognized accrediting agencies to discuss developing a consensus on the definition of reportable adverse incidents and defining the minimum peer review/quality assurance standards necessary for accredited outpatient surgery facilities. • Because the ASPS feels so strongly that continuing medical education is vital for risk management and patient safety–related events, we have moved forward to require that 20 hours of the total hours required during the 3-year continuing medical education cycle be related directly to patient safety education. The ASAPS will be invited to dedicate a portion of their continuing medical education program to patient safety, as well. This will be done conjointly with development of a patient safety Tracking Operations and Outcomes for Plastic Surgeons (TOPS) module as part of the growing online procedural information database. TOPS is not only accurate but also tracks our patient safety initiatives and outcomes. • The ASPS will continue to evolve patient safety advisories and advance safety-related publications and policies to be readily distributed not only to our members but to the public as well. Several publications highlighting patient safety in office-based facilities have been published in Plastic and Reconstructive Surgery. Patient safety is our priority and primum non nocere, “do no harm,” is our motto. This is in lockstep with the patient safety principles for office-based surgery utilizing moderate sedation/analgesia, deep sedation/analgesia, and general anesthesia that have been approved by the American College of Surgeons, the American Medical Association, and the American Society of Plastic Surgeons 3: ○ Core Principle #1: Guidelines or regulations should be developed by states for office-based surgery according to levels of anesthesia defined by the American Society of Anesthesiologists’ “Continuum of Depth of Sedation” statement dated October 13, 1999, excluding local anesthesia or minimal sedation. ○ Core Principle #2: Physicians should select patients by criteria, including the American Society of Anesthesiologists’ Patient Selection Physical Status Classification System, and so document. ○ Core Principle #3: Physicians who perform office-based surgery should have their facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations, the Accreditation Association for Ambulatory Health Care, the American Association for Accreditation of Ambulatory Surgery Facilities, the American Osteopathic Association, or a state-recognized entity such as the Institute for Medical Quality, or they should be state licensed and/or Medicare certified. ○ Core Principle #4: Physicians performing office-based surgery must have admitting privileges at a nearby hospital, or a transfer agreement with another physician who has admitting privileges at a nearby hospital, or maintain an emergency transfer agreement with a nearby hospital. ○ Core Principle #5: States should follow the guidelines outlined by the Federation of State Medical Boards regarding informed consent. ○ Core Principle #6: States should consider legally privileged adverse incident reporting requirements as recommended by the Federation of State Medical Boards and accompanied by periodic peer review and a program of Continuous Quality Improvement. ○ Core Principle #7: Physicians performing office-based surgery must obtain and maintain board certification by one of the boards recognized by the American Board of Medical Specialties, the American Osteopathic Association, or a board with equivalent standards approved by the state medical board within 5 years of completing an approved residency training program. The procedure must be one that is generally recognized by that certifying board as falling within the scope of training and practice of the physician providing the care. ○ Core Principle #8: Physicians performing office-based surgery may show competency by maintaining core privileges at an accredited or licensed hospital or ambulatory surgical center for the procedures they perform in the office setting. Alternatively, the governing body of the office facility is responsible for a peer review process for privileging physicians based on nationally recognized credentialing standards. ○ Core Principle #9: At least one physician, who is credentialed or currently recognized as having successfully completed a course in advanced resuscitative techniques (advanced trauma life support, advanced cardiac life support, or pediatric advanced life support), must be present or immediately available with age- and size-appropriate resuscitative equipment until the patient has met the criteria for discharge from the facility. In addition, other medical personnel with direct patient contact should at a minimum be trained in basic life support. ○ Core Principle #10: Physicians administering or supervising moderate sedation/analgesia, deep sedation/analgesia, or general anesthesia should have appropriate education and training. In the end, putting patient safety first simply comes down to being a caring physician and exercising prudent judgment in the care of our patients. When in doubt, don’t do it! Always do right. This will gratify some people and astonish the rest. —Mark Twain
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