Page 31 - Part 1 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

Regarding claims arising out of the PACU, one of the elements

frequently found missing in the claims review was patient status
at hand-off to PACU nurses. There should be a systematic

handoff of anesthesia care between anesthesia providers and
nurses in PACU. The ASA Standard is that a member of the

anesthesia team accompany the patient to the PACU, and
upon arrival in the PACU, re-evaluate the patient and give

a verbal report to the responsible PACU nurse. This should
be documented with times and with oxygenation status. The

Anesthesia Quality Institute has hand-off criteria available for
transfer of care from the procedure room to the ICU and also to

PACU.
14

The other main element missing in the documentation
was determination of patient status prior to discharge.

Discharge of the patient too early and without oversight by
the anesthesiologist are common allegations. There should

be assessment criteria used by PACU nurses that have been
developed and approved by the Anesthesia Department.

Anesthesia needs to see the patient and agree that it is the
appropriate time for discharge and this decision needs to be

properly documented. In cases where the patient is advised to
stay overnight and refuses, that refusal should be noted along

with instructions given to the patient for return as well as the
risk to the patient for refusal to stay. If not documented, it can be

inferred that the actual communication never took place.

An additional, although less frequent, documentation issue

uncovered in our claims review is untimely notes. Notes should
be completed the same day. There are hazards associated with

delayed documentation as memory can interfere with accuracy,

14 https://www.asahq.org/standards-and-guidelines/standards-for-postanesthesia-care

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