Balancing Efficiency and Safety During Pre–Anesthesia Evaluations
CME Information
Sponsored by:
NORCAL Mutual Insurance Company, a member of the NORCAL Group. The NORCAL Group of companies includes NORCAL Mutual Insurance Company, Medicus Insurance Company and FD Insurance Company.
NORCAL Mutual Insurance Company is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
For questions, please call the Risk Management Department at 855.882.3412.
Method and Medium
To obtain CME credit, read the article then take the quiz and fill out the evaluation form. You can print or email your CME certificate from this application.
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Original Release Date: December 15, 2016
Expiration Date: January 1, 2019
Learning Objectives
By reviewing medical professional liability claims and/or emerging topics in healthcare risk management, this enduring material series will support your ability to:
Assess your practice for risk exposures.
Apply risk management best practices that increase patient safety and reduce medical professional liability claims.
Target Audience
Anesthesiologists, certified registered nurse anesthetists, members of surgical teams, risk managers and administrators.
Credit Designation Statement
NORCAL Mutual Insurance Company designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure Policy
As an ACCME accredited provider, NORCAL Mutual Insurance Company requires planners, reviewers or authors who influence or control the content of a CME activity to disclose financial relationships (of any amount) they have had with commercial interests associated with this CME activity during the year preceding publication of the content.
Any identified conflicts of interest are resolved prior to the commencement of the activity.
Disclosures
Individuals involved in the planning, reviewing or execution of this activity have indicated they have no relevant financial relationships to disclose.
Editor
Mary–Lynn Ryan
Risk Management Specialist,
NORCAL Mutual
Content Advisors
Jaan E. Sidorov, MD
Chair, NORCAL Mutual, FD Insurance and Medicus
Patricia A. Dailey, MD
Director, NORCAL Mutual, FD Insurance and Medicus
Rebecca J. Patchin, MD
Director, NORCAL Mutual, FD Insurance and Medicus
William G. Hoffman, MD
Family Practice Content Advisor
During a pre–anesthesia evaluation prior to elective surgery, anesthesiologists can be under a tremendous amount of pressure to go forward with a surgery that for patient safety reasons should be postponed or cancelled.
Production pressure – the actual or internalized pressures or incentives on a person to prioritize production over safety – can be found at the root of many lawsuits filed against anesthesiologists. Production pressure can push anesthesiologists to incrementally deviate from safe practices, which surreptitiously increases the risk of patient injury.1,2 Pressure on anesthesiologists comes from many directions. Research indicates it is felt most keenly from surgeons and administrators.3 Consequently, when an anesthesiologist fails to cancel or postpone a surgery that is too risky, every individual who helped create the pressure to go forward with the procedure can share the blame for the adverse outcome.
This article is primarily focused on anesthesiologists and administrators who create policies and procedures affecting the cancellation or postponement of surgery by an anesthesiologist for patient safety reasons. However, anesthesiologist decision–making does not happen in a vacuum. All members of the surgical team are encouraged to consider the risk management recommendations following the case studies in this article.
“Without a culture in which safety trumps production, adequate staffing, clear policies and procedures, adequate working conditions, and front–line empowerment and resources, proclamations about the importance of safety are belied by actual events.”
Carayon P. Production Pressures. 2007. Patient Safety Network WebM&M. Available at: https://psnet.ahrq.gov... (accessed 10/20/2016).
According to an anesthesia expert in the following case, the defendant anesthesiologist should have told the surgeon the patient should be rescheduled when there were more hands available.
Case One
Allegation:
The procedure should have been rescheduled because there was insufficient staff to appropriately manage the high–risk patient.
A 40–year–old morbidly obese patient with diabetes, hypertension and sleep apnea was scheduled for breast–reduction surgery in the hospital. Because of scheduling conflicts, the case was moved to a Saturday. On Saturdays, the hospital only had one operating room open for elective surgeries. Therefore, only an anesthesiologist, surgeon, scrub nurse, circulating nurse and physician assistant were scheduled to be on duty. (A CRNA was on call.) The anesthesiologist conducted a pre–surgical examination and determined the patient had a difficult airway and was at increased risk for anesthesia complications. The surgeon was using a surgical table that allowed the patient to be moved into a sitting position, to ensure breast symmetry. However, the table was too small and positioning the patient was difficult. The anesthesiologist requested a larger table. The surgeon refused, because the larger tables could not be used to position the patient in an upright position. The patient was sedated and the anesthesiologist attempted intubation, but because of the patient’s obesity, her position on the table and lack of proper tools, she was not successful.
The surgery was cancelled and the anesthesiologist started to awaken the patient, who quickly became very agitated. The patient pulled off the monitors and face mask, causing the tubing to become disconnected from the oxygen source. Because of the patient’s size, the surgical team had trouble restraining her. After struggling for a few minutes, the patient slowly became less agitated and the team was able to reconnect the oxygen and monitors. They then discovered she had no pulse. They were able to revive the patient, but she suffered significant anoxic brain injury.
The family filed a medical liability lawsuit against all of the providers involved in the patient’s care.
The anesthesiologist was the target defendant in the lawsuit because she decided to go forward with the procedure without sufficient assistance. According to defense experts, the anesthesiologist should have anticipated the need for assistance from another anesthesia professional and should not have gone forward without it. Unfortunately, she allowed production pressures to overpower her well–considered misgivings about going forward with the case. The anesthesiologist knew the intubation would be challenging, but wanted to attempt it alone; she wanted to prove to herself and the administration that she could do it. Also, during the pre–surgical examination, the patient had vociferously complained about the earlier surgery cancellation, which prompted the anesthesiologist to assure her the surgery would go forward. Finally, the anesthesiologist had recently cancelled another of the surgeon’s procedures and he had been extremely unpleasant about it. She dreaded having to go through the experience again. In retrospect, however, the anesthesiologist acknowledged that because of the patient’s comorbidities, no anesthesiology assistance, the surgeon’s refusal to use a table that accommodated the patient and the fact that the surgery was not urgent, she should have insisted on postponing the surgery.
Although there are plenty of legitimate reasons for an anesthesiologist to postpone or cancel surgical procedures for additional evaluation and treatment, it is a frequent source of conflict between anesthesiologists and surgeons.3 Consider the following strategies:
Anesthesiologists4
Ask the advice of a trusted colleague if you are unsure of whether surgery should be cancelled.
Anticipate and be prepared to resolve conflicts that may arise with surgeons over recommendations to cancel a procedure.
Resolve the conflict in a private place.
Clearly communicate your reasons for recommending cancellation.
Utilize facility inclusion/exclusion criteria, clinical guidelines, algorithms and other patient safety tools.
Actively listen to the surgeon’s reasons for wanting to go forward with the surgery.
Do not interrupt.
Accept feedback constructively.
Identify the precise source of the conflict.
Involve a third party (to act as a mediator) when necessary.
Resolve the conflict from a nonjudgmental point, taking all pertinent factors into consideration.
Participate in interdisciplinary team training.
Learn how to identify when production pressure is affecting patient safety and have a plan for bringing the pressure level to a point where patient safety is not compromised.
Administrators5
Identify systems factors that contribute to production pressures and implement interventions to address those factors.
Ensure there are sufficient clinicians and staff to perform all of the tasks necessary to maintain patient safety.
Do not judge staffing sufficiency solely on the number of individuals scheduled; consider their skills, knowledge and experience.
Ensure staffing is sufficient for both usual and unusually busy days.
Understand what causes a day to be unusually busy (e.g., more patients scheduled, more complex patients, unplanned staff/clinician absences).
Create policies and procedures that will empower staff and clinicians to identify when the level of production has become unsafe and obtain assistance, solve problems or slow production.
Do not discourage or punish clinicians or staff members who follow procedures to control production pressure.
Encourage and support interdisciplinary team training.
The Centers for Medicare and Medicaid Services (CMS) maintains oversight for compliance with the Medicare health and safety standards for facilities serving Medicare and Medicaid beneficiaries. Compliance surveys (inspections) are carried out by State Survey Agencies whose surveyors use the State Operations Manual (SOM) to verify how well a practice or facility complies with the "conditions of participation" (CoPs) or other CMS requirements.6 The SOM can also be used by ambulatory surgery center anesthesiologists and administrators to create safer patient inclusion/exclusion policies and procedures. According to Interpretive Guidelines §416.42(a)(1) in Appendix L of the SOM, which addresses pre–surgical anesthesia risk assessment, the pre–surgical/pre–anesthesia assessment policies and procedures should ensure each patient gets an individualized assessment of anesthesia–related and procedural risks in a consistent manner just prior to every surgical procedure.7 “The purpose of the exam…is to evaluate…whether the risks associated with the anesthesia that will be administered and with the surgical procedure that will be performed fall within an acceptable range for a patient having that procedure in an ASC.”7
It is worth noting, surveyors are instructed to “ask the ASC’s leadership whether they can point to any cases where an assessment resulted in a decision not to proceed with the surgery.”7 If there are no such cases, they should ask the ASC to “explain how its patient selection criteria assure that there is an acceptable level of anesthesia and procedural risk for every patient scheduled for surgery in the ASC – for example, do they use patient admission criteria that exclude higher risk patients?”7 If so, they are supposed to ask to see those criteria.7 Consequently, there is an expectation that surgeries will be cancelled or postponed. When assessing whether the pre–surgical assessment process is safe, the surveyors are also encouraged to review cases where a patient died or needed to be transferred to a hospital, and to discuss the pre–surgical assessment of the patient in those cases with the physician who conducted the assessments to explore the basis on which the patient was found to be suitable for the surgery and anesthesia.7 Therefore, it is particularly important for anesthesiologists to appropriately document the reasoning and support for a decision to go forward with high–risk patients.
American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. anesthesiology.pubs.asahq.org... (accessed 10/19/2016).
Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Available at: www.alabmed.com... (accessed 10/19/2016).
2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Available at: http://content.onlinejacc.org... (accessed 10/19/2016).
The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management. This document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Available at: www.hrsonline.org... (accessed 10/19/2016).
Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Available at: http://annals.org... (accessed 10/19/2016).
Society for Ambulatory Anesthesia. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. http://ether.stanford.edu... (accessed 10/19/2016).
American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator. Available at: www.surgicalriskcalculator.com (accessed 10/19/2016).
Anesthesiologists working in high–volume endoscopy clinics can feel a tremendous amount of pressure to “go with the flow” and push the limits of what’s safe in an ambulatory environment. If the endoscopy center practice is premised on the idea that all endoscopy cases can be performed with sedation until proven otherwise, and changing the plan leads to delay, lost revenue, bad feelings and extra work, the incentive to perform a procedure on a too–high–risk patient as scheduled can be overwhelming.8 The following case study is based on a scenario described by a NORCAL–insured anesthesiologist who works at a high–volume endoscopy center. Her experience with a cancellation shows how excellent patient criteria guidelines and her own dedication to patient well–being can alleviate some of the pressure when she must make difficult decisions about cancelling procedures.
Case Two
Issue:
The anesthesiologist was under pressure to go forward with a high–risk patient.
The patient was a middle–aged man with a history significant for a myocardial infarction (MI) three months previously and a more recently placed stent. He was experiencing gastrointestinal bleeding, and had therefore discontinued his anticoagulants. He was an ASA category 4. His GI specialist (one of the endoscopy center owners and the employer of the anesthesiologist in this case) scheduled the patient for an endoscopy in the endoscopy center to determine the etiology of the bleeding. However, the endoscopy center had guidelines that clearly excluded patients with ASA classifications over 3 and patients who had suffered an MI within 6 months.
The anesthesiologist first encountered the patient the morning of his procedure, and reviewed his medical information. She determined the patient was too high risk for treatment at the endoscopy center. She contacted the patient’s GI physician and recommended cancelling the procedure. The GI physician was resistant to cancelling the procedure because he needed to know what was causing the patient’s bleeding. The anesthesiologist cited the endoscopy center’s guidelines in support of her opinion. The procedure was cancelled and rescheduled at the hospital.
The anesthesiologist in this case was in a difficult situation for a number of reasons. The GI physician had the power to terminate her employment at the endoscopy center and was a more experienced physician. Despite this power imbalance, she was charged with the ultimate decision about whether the procedure would go forward. Knowing when to cancel a procedure is a skill that develops over time. During her early practice years, when a patient did not squarely fit into patient selection criteria, this anesthesiologist discussed cases with a more experienced, trusted anesthesiology colleague. Over time, she developed her own sense for when patient risk demanded cancellation.
She couldn’t blame the GI physician for vigorously advocating for the endoscopy being done as quickly as possible, due to the patient’s bleeding. Since the endoscopy center had good patient inclusion/exclusion criteria for her to use, she was able to convince the physician that the threat the procedure posed to the patient’s well–being demanded cancelling the procedure. She was not willing to put the patient in danger to safeguard her employment.
This anesthesiologist was working in an environment with well–crafted patient inclusion/exclusion criteria for the particular practice. The efficacy of the criteria was no accident. There are no national guidelines for creating patient selection criteria in an endoscopy center. The clinicians, staff and administrators of the group worked together to create the patient selection guidelines. The guideline discussions included patient variation and inclusion objectives that were not associated with patient well–being, for example, maintaining the procedure schedule, paying the bills, keeping patients satisfied and professional fulfillment. Consequently, using a team approach to create patient selection criteria can be a daunting task. However, it can result in the creation of guidelines everyone can live with that are flexible enough to provide guidance in challenging situations. For example, when a patient uses oxygen at night for sleep apnea, but the endoscopy center’s patient selection criteria excludes patients who use home oxygen, a strict reading of the criteria requires cancellation of the surgery. However, patients with sleep apnea may be safely served in an endoscopy center. For patients using oxygen for sleep apnea, the underlying patient safety reasons for the exclusion criteria may not apply. Criteria should be flexible enough to allow the procedure to go forward after careful assessment of the patient and facility resources.
When an anesthesia–related problem arises in an ambulatory setting, the anesthesiologist will have fewer resources to address it than would be available in a hospital.9 The availability of special equipment, consultation services and staff experience can vary between venues. For example, the ancillary and support personnel at an endoscopy center may have little experience in dealing with an adverse event, because they are uncommon in this venue. There also will not be as many skilled staff and clinicians available to respond to a call for help and ideal equipment may not be available. Consequently, consistent application of appropriate patient selection criteria is important.8
Given the limitations of treatment once an adverse event has occurred in a high–volume ambulatory surgery center, it seems reasonable to focus on prevention. Consider the following recommendations:8,10
Create and comply with concrete patient inclusion/exclusion criteria that are not overly proscriptive, but provide the impetus for making a choice against sedation when it is necessary.
Include a set of broad guidelines for the consideration of general anesthesia instead of sedation.
Consider whether the venue is adequately equipped to deal with an emergency that may arise from the surgical procedure and/or the patient’s comorbidities.
Ensure policies and procedures are in place that outline criteria a physician must complete and document that supports the basis on which a patient outside the exclusion criteria is found to be suitable for surgery in the ASC setting.
Have a multi–disciplinary team “huddle” each morning during which planned cases are reviewed to identify and prepare for potential problems.
“Normalization of deviance” refers to a gradual erosion of acceptable safety practices and standards that becomes “normalized” because no accidents have occurred. The process occurs in the interest of efficiency – slight deviations from safe practices help keep the schedule moving. Because outcomes are successful and nothing catastrophic has happened, the increasing risk is overlooked.11
Normalization of deviance commonly affects the pre–anesthetic evaluation process.2 A pre–anesthetic evaluation is frequently performed shortly before surgery when there is significant pressure to move the case forward. Slowly and surely over the course of time, an anesthesiologist’s evaluation may become briefer and briefer, even though it is contrary to established patient safety policies and procedures. The abbreviation continues because there appears to be no downside to it, but sooner or later a patient is injured. The cause of the injury is often traced back to shortcuts in the evaluation process.2 Although the deviation may occur so gradually the anesthesiologist barely notices it, in the eyes of an attorney it may look like a major deviation from patient safety protocols and practices and be used as evidence of negligence. Case Three shows evidence of normalization of deviance in the pre–anesthetic evaluation.
A simple procedure in an excellent ambulatory surgery center can have disastrous results when a patient has a dangerous combination of comorbidities. In the following case, the anesthesiologist decided to push the envelope with a high–risk patient and allow surgery to go forward. Unfortunately, the information he used to make that decision was not reliable. The physician would have had a more accurate profile if he had a complete evaluation that considered whether surgery in an ASC would be proper.
Case Three
Allegation:
The patient was too high risk for ambulatory surgery.
A 65–year–old female patient was admitted to an ambulatory surgical center for minor elective surgery. She had advanced heart disease, for which she used home oxygen; a pacemaker; morbid obesity; diabetes; and severe sleep apnea, for which she refused treatment with CPAP. A week prior to surgery, the patient underwent a pre–operative evaluation with her primary care physician. The PCP “cleared” the patient for surgery, and noted she was ASA category 3.
The anesthesiologist conducted a pre–anesthesia evaluation and examined the patient shortly before surgery. The patient informed the anesthesiologist she had been seen by her cardiologist the previous day and he had “cleared” her for surgery. (No cardiology notes were available in the patient’s file and the anesthesiologist did not contact the cardiologist.) The anesthesiologist determined the patient was ASA 3, and that surgery was not contraindicated, despite the patient’s high risk. He decided to use sedation for the surgery. After advising the patient of the additional risks posed by her comorbidities and informing her that she could choose to cancel that day and have the surgery done at a hospital at a later date, the patient indicated that she understood the risks and wanted to go forward as planned. Ten minutes into surgery the patient became unresponsive. The surgery was halted and resuscitative measures were undertaken, but the patient expired. The likely cause of death was determined to be respiratory arrest as a result of sleep apnea that resulted in cardiovascular collapse, cardiac arrest and hypoxic encephalopathy.
The patient’s family filed a malpractice lawsuit against all members of the healthcare team.
The anesthesiologist was the target defendant in the lawsuit because he controlled the ultimate decision of whether to go forward with the surgery and chose the type of anesthesia. The anesthesiologist testified he considered cancelling the procedure due to the patient’s high–risk profile, but the clearances by the patient’s PCP and cardiologist, the short duration of the surgery and the patient’s strong desire to have the surgery convinced him to go forward. As for the PCP’s classification of the patient as an ASA category 3, the anesthesiologist assumed the PCP had greater familiarity with the patient than he did, which pushed him toward a category 3 designation for the patient instead of a 4. According to the anesthesiology defense expert, the patient could not legitimately be classified as an ASA 3; she was an ASA 4. The anesthesiologist’s reliance on the patient’s report of being cleared by her cardiologist was also problematic. The cardiologist did not “clear” the patient for surgery; the appointment with the cardiologist the day prior to surgery was a follow–up appointment to check the function of the patient’s pacemaker. Although the working status of the pacemaker was an important factor, there were other significant cardiac issues the anesthesiologist should have considered prior to going forward. Furthermore, the cardiology defense expert believed the patient should not have been allowed to undergo any type of elective surgery because of her very high risk for perioperative cardiac events. Had the anesthesiologist contacted the cardiologist directly, he most likely would have had a far more accurate set of facts upon which to make a decision.
The pre–anesthesia evaluation of a patient with cardiac disease has two main objectives: to identify and modify cardiac risk and determine whether the patient would be better served in an inpatient setting.9 Over–reliance on reports that endeavor to “clear” a patient for surgery is risky because consultants may not be aware of an anesthesiologist’s expectations of a preoperative “clearance.”12 As the foregoing case indicates, a specialist may not even be aware that an anesthesiologist is using the results of his or her examination of the patient to determine whether ambulatory surgery is appropriate. Consider the following recommendations:
Anesthesiologists9,12
If the patient presents to the pre–surgical anesthesia examination on the day of surgery without enough information to determine if the patient can safely undergo the planned procedures, postpone the procedure until adequate information can be obtained.
Do not rely on a patient’s report of being “cleared” for surgery.
Do not over–rely on a PCP’s or specialist’s “clearance” of a patient for surgery.
When in doubt, contact the PCP or specialist.
Use clinical guidelines to become familiar with anesthesia risks associated with various comorbidities. (See, for example, the list of clinical guidelines in the risk management recommendations following Case One.)
If you believe the patient may be too high risk for ambulatory surgery due to comorbidities, speak directly with the patient’s PCP and/or specialist to help you stratify the risks.
If you are not convinced the patient fully understands the risks of the procedure, postpone the procedure until the patient understands the risks and alternatives. General anesthesia and having the procedure done in the hospital are alternatives that should be discussed during the anesthesia informed consent process with a high–risk patient.
If you determine a patient is too high risk for ambulatory surgery, check with the hospital to determine if/when the patient could be accommodated on the hospital’s surgery schedule and inform the surgeon of the alternative solution.
Administrators9,12,13
Use the information obtained in the pre–surgical evaluation to determine if the patient will benefit from evaluation by an anesthesiologist prior to the day of surgery. Such an evaluation can be used to determine whether the surgery has been scheduled in the correct venue.
Review cases in your practice that involved adverse events, near misses and hospital admissions and analyze whether your patient selection/exclusion criteria are effectively managing patient safety risks. If not, make adjustments.
Pre–surgical Consultants12
Do not use the term "cleared for surgery" with the patient or a colleague requesting a pre–surgical assessment. It may imply the procedure presents no risk to the patient. Instead, provide an assessment of perioperative risks and, if necessary, a plan for optimization.
The process of weighing production against the safety of a high–risk patient will rarely be straightforward. Policies and procedures should be in place that provide the impetus for making a choice against going forward with a scheduled procedure that is too high risk. Anesthesiologists must recognize and guard against normalization of deviance in pre–anesthesia assessment practices and must find ways to comfortably resolve conflict with clinicians and administrators who may pressure them to go forward with procedures that should be cancelled. Using the strategies introduced in this article can help refocus a risk assessment on patient well–being when production pressure is high.
The NORCAL documents referenced in this article, along with many other Risk Management Resource documents and past editions of the Claims Rx, are available in the Risk Solutions area of MyACCOUNT, or by policyholder request at 855.882.3412.
Kirsner K, Biddle C. Production pressure and a culture of deviance in the insular operating room and the consequences of their "normalization": have we reached a Hooper moment?
The Internet Journal of Law, Healthcare and Ethics. 2012;8(1). Available at: http://ispub.com... (accessed 10/20/2016), citing, Gaba D, Howard S, Jump B. Production pressure in the work environment: California Anesthesiologists’ attitudes and experiences. Anesthesiology. 1994; 81(2):488–500.
Kurtz R. Normalization of Deviance and its Impact on Anesthesia and Healthcare: Q&A With Anesthesiologist Dr. Thomas Schares of Somnia Anesthesia Services. 2011. Becker’s Hospital Review. Available at: www.beckershospitalreview.com... (accessed 10/20/2016).
DeMaria S, Neustein SM. Production Pressure, Medical Errors, and the Pre–Anesthesia Checkout. M.E.J. Anesth 20(5), 2010 631–638, citing Gaba D, Howard S, Jump B. Production pressure in the work environment: California Anesthesiologists’ attitudes and experiences. Anesthesiology. 1994; 81(2):488–500.
Katz, JD. Conflict and its resolution in the operating room. Journal of Clinical Anesthesia. 2007;19(2):152–158.
Carayon P. Production Pressures. 2007. Patient Safety Network WebM&M. Available at: https://psnet.ahrq.gov... (accessed 10/20/2016).
Centers for Medicare & Medicaid Services. Survey & Certification – General Information. Page last modified 11/5/2013. Available at: www.cms.gov... (accessed 10/20/2016).
CMS. State Operations Manual Appendix L – Guidance for Surveyors: Ambulatory Surgical Centers. Available at: www.cms.gov... (accessed 10/20/2016).
Case Report From the Anesthesia Incident Reporting System. ASA Monitor.2016;80:48–49. Available at: http://monitor.pubs.asahq.org... (accessed 10/20/2016).
Stierer TL, Collop NA. Preoperative testing and risk assessment: perspectives on patient selection in ambulatory anesthetic procedures. Ambulatory Anesthesia. 2015;2:67–77. Available at: www.dovepress.com... (accessed 10/20/2016).
Attri JP, et al. Conflicts in Operating Room: Focus on Causes and Resolution. Saudi J Anaesth. 2015;9(4):457–463. Available at: www.ncbi.nlm.nih.gov... (accessed 10/20/2016).
Prielipp RC, Magro M, Morell RC, Brull SJ. The Normalization of Deviance: Do We (Un)Knowingly Accept Doing the Wrong Thing? Anesthesia & Analgesia. 2010;110(5):1499–1502. Available at: www.aana.com... (accessed 10/20/2016).
Brovender A. 2015. Use and Effect of Quantitative Clinical Feedback for Learning and Quality Improvement in Anesthesiology. Available at: https://tspace.library.utoronto.ca... (accessed 9/22/2016).
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