August 2004 Bulletin

Patient safety in the ASC

AAOS develops checklists to ensure patient safety

By the ASC/POE Project Team

How many haircuts does it take to pay for a myringotomy? That’s the question John Ford, MD, and Wallace Reed, MD, asked back in 1968 when they began to explore the concept of “surgicenters.” These “fathers” of the “surgicenter” or ambulatory surgery center (ASC) were responding to the plight of an uninsured barber whose two children were hospitalized in Phoenix for myringotomies. At the time, accepted medical practice was to hospitalize children for two nights.

The ASC was devised to eliminate the expense of hospitalization and minimize the cost of the service itself. These goals were met by conserving patients’ time, keeping operating and recovery room times to a minimum, and achieving turnover times that rarely exceeded 15 minutes (and were usually less than 10 minutes).

The first ASC, the Phoenix Surgi-center, opened its doors in February 1970 and the rest, shall we say, is history.

ASCs today

Each year, more than 7 million surgeries are performed in the approximately 3,300 ASCs in the United States. In a 2002 survey by specialty, orthopaedics accounted for 10 percent of ASC volume.1 Medicare patients account for 25 percent of the procedures in an ASC, and a recent survey of these Medicare patients found that 98 percent were satisfied with their ASC experience, citing convenient scheduling, reduced paperwork, lower cost, more convenient location and parking, less waiting, and a more organized and personable staff.2

A combination of accreditation and/or licensure and certification provides regulation and oversight of ASCs. Accreditation is a voluntary triennial process administered by a not-for-profit organization. The accrediting body consults with and evaluates ASCs, suggesting ways to improve services and set and meet performance standards. Licensure and Medicare/Medicaid certifications for ASCs are mandatory, periodic, and may include unannounced inspections funded by tax dollars. The inspections identify deficiencies and enforce, via sanctions and fines, adherence to regulatory standards.

State and Medicare licensure and accreditation require appropriate design and construction of ASCs. Licensure is required in all states for Medicare certification; some states require accreditation for licensure. Forty-three states require that all ASCs be licensed, regardless of Medicare certification. Medicare has currently certified 85 percent of existing ASCs, although nearly one third have not been recertified in more than five years.

Patient safety in the ASC

There is a perception that patient safety in ASCs is generally better than in other healthcare settings.3 This may be due in part to the fact that ASCs generally have older, more experienced physicians on staff, attract younger and healthier patients, and/or provide less complex procedures. Early concerns about safety led to improved preoperative evaluation, intraoperative monitoring and postoperative care being designed into ASCs.

The current trend, however, is for physicians to perform more complex procedures that, as yet, do not appear on the CMS list of approved ASC procedures, which many believe is woefully out-of-date. This may increase the risk to patient safety. Patients may not receive adequate preoperative medical evaluation and clearance by their primary care physician for some of the more complex procedures. This highlights the importance of careful, uniformly applied privileging standards, and regular recertification/reaccreditation to ensure oversight of performance.

Procedures performed in ambulatory surgery centers are generally subject to the same risks and errors as those performed in traditional hospital-based operating suites. In addition, some risks are more likely to be encountered in the ASC (e.g. staffing issues, equipment concerns, emergency training procedures). These issues are further discussed in the AAOS report on “Patient Safety in the ASC” available at

Communication in the ASC

Communication at all levels is critical in ensuring a safe environment and minimizing errors in the ASC. Consequently, the AAOS has focused considerable attention on this issue. Communication must begin before the procedure, in the physician’s office. It must continue not only at the ASC but also afterward, when the patient returns to the physician’s office for follow-up.

In the physician’s office. Communication begins at the physician’s office where the decision to perform a procedure is made, explained, consented to, and scheduled. Preoperative preparations and postoperative arrangements also are made in the office setting. A procedure-specific checklist can be invaluable in assuring completion of these tasks.

At the ASC. At the ASC, checklists can also help verify preoperative preparations, postoperative arrangements, and the three critical identifiers: the correct patient, the correct procedure, and the correct site. The AAOS Sign Your Site guidelines should be scrupulously followed, including the requirements that:

Postoperative evaluation and discharge instructions should be complete and thoroughly documented, preferably with the aid of procedure-specific checklists. Special attention should be given to making sure that the patient or responsible person understands medication and emergency assistance instructions. Provisions for handling any language or hearing problems should be made well in advance.

Back to the physician’s office. The final link in the chain of communications occurs back in the physician’s office, which should have a copy of the operative note, discharge instructions given, pathology report, and X-rays or other pertinent images at the time of the first follow-up visit, or, if not possible, as soon as they are available.

The AAOS and ASC patient safety

The AAOS is dedicated to improving patient safety by implementing programs to ensure that patient safety is a cornerstone of orthopaedic practice. To assist physicians’ efforts to improve patient safety in the ASC, the AAOS has developed concise patient safety checklists to be used preoperatively and postoperatively. These checklists are best clipped directly to the patient chart, and completed and signed by the orthopaedic surgeon.

The preoperative checklist ensures that the surgeon has considered issues related to this particular patient’s safety for the specific procedure and that certain safety-related processes have been performed prior to entering the operating room. The postoperative checklist ensures that the surgeon considers issues related to the safety of the patient at discharge. These checklists are available and can be downloaded free of charge from the AAOS Web site: (pre-operative) and (postoperative).

By focusing on improving communication and using these checklists to ensure that crucial information is shared, orthopaedic surgeons will take a critical first step to prevent medical errors and ensure patient safety in the ASC.

The Ambulatory Surgery Center/Practitioner Office Errors Project Team is comprised of Steven S. Fountain, MD, chair (; Dale R. Butler, MD (; Jack Childers, MD (; Michael J. Goldberg, MD; Naomi Kuznets, PhD, consultant ( and Belinda Duszynski, clinical quality improvement coordinator, research and scientific affairs department (


  1. Federated Ambulatory Surgery Association (FASA) Web site, “Frequently Asked Questions” (
  2. Patient Satisfaction with Outpatient Surgery: A National Survey of Medicare Beneficiaries. DHHS Office of the Inspector General, December 1989. (OAI-09-88-01002).
  3. Miller KA, Martin DL. Differences between inpatient and ambulatory surgical site infection rates are not explained by risk-adjustment. Centers for Disease Control and Prevention, Fourth Decennial International Conference on Nosocomial and Healthcare Associated Infections, March 2000. (Abstract appears in Infect Control Hosp Epidemiol 2000 Feb;21(2):86-174)

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