Patient Safety Strategies for Gastroenterologists

Lisa McCorkle, MSN, CPHRM, Senior Patient Safety Risk Manager, The Doctors Company

Keeping patients safe is a significant concern for all gastroenterologists. When performing procedures, consider the following patient safety strategies.

Preprocedure

Conduct a preprocedure evaluation that includes reviewing the patient’s records for underlying medical conditions that may affect care, such as obstructive sleep apnea or airway problems. Elicit any history of problems with sedation, prior surgery, or anesthesia. Perform a focused physical examination and obtain preprocedure laboratory testing if indicated. Review current medications and allergies. Document the preprocedure medical evaluation and acknowledge the review of any specialty consultation reports.

Use the American Society of Anesthesiologists (ASA) Physical Status Classification System to assign an ASA risk score to each patient. The patient’s ASA risk score provides key information for selecting the appropriate setting for the procedure. For example, a patient with an ASA score of IV would not be a suitable candidate for an endoscopic procedure in an office setting. Be aware of each facility’s staff credentials and its capabilities and limitations.

Provide patients with clearly written preprocedure instructions, including the need for NPO status. Document in the medical record that all critical information, like NPO status, has been confirmed with the patient.

During the Procedure

Implement and maintain a comprehensive infection control plan. Include active infection prevention surveillance and meticulous endoscopic reprocessing protocols. Emphasize ongoing education and evidence of competency for the staff involved in the plan.

Follow patient safety guidelines for moderate sedation (conscious sedation). Resources include the following:

• Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018, ASA.
• Statement of Granting Privileges for Administration of Moderate Sedation to Practitioners, ASA.
• Guidelines for Sedation and Anesthesia in GI Endoscopy, American Society of Gastrointestinal Endoscopy (ASGE).
• Guidelines for Safety in the Gastrointestinal Endoscopy Unit, ASGE.

Guidelines include monitoring the following throughout the procedure:

• Blood pressure.
• Ventilatory function by respiratory rate and capnography.
• Oxygen saturation by pulse oximetry.
• Heart rate and function by electrocardiogram.
• Depth of sedation/level of consciousness.

Monitoring equipment alarms should be audible throughout the procedure and never be silenced.

The following are additional strategies for moderate sedation (conscious sedation):

• Designate an individual to monitor the patient throughout the procedure (someone other than the practitioner performing the procedure). The designated individual must be trained to recognize and respond to airway complications.
• Maintain current ACLS certification (or PALS for pediatric patients) for all practitioners who supervise or administer moderate sedation.
• Adhere to the guidelines indicated for the particular sedative given (for example, propofol).
• Have age-appropriate emergency medications and equipment readily available for patients.
• Ensure appropriate postprocedure observation and monitoring.

Postprocedure

Maintain tracking systems for test results and follow-up exams. Tracking test results is a critical patient safety function. Verify that your manual office system or EHR will alert you if a result or report is not received. Holding the record or relying solely on a follow-up appointment are not recommended solutions.

A task list generated by an EHR, a specimen log, or a copy of the requisition or order form—any of which can be checked periodically—provides a reliable safety net. When you review the report or results, verify that the correct test was performed and the correct results were returned. Advise patients that the practice will contact them regarding every test or procedure and that they should contact the office if they do not receive results in a reasonable time frame. Do not encourage a “no news is good news” approach.

Like test result tracking, a patient reminder system should be in place to ensure that patients are monitored for reexamination or follow-up. Maintain a reminder system to generate and send letters at appropriate intervals. If a patient who meets the risk criteria fails to respond to reminders, help the individual make an informed decision by providing education about the risks of ignoring treatment recommendations. File all documentation in the medical record. (For further information, see our article, “Laboratory and Diagnostic Test Tracking in Ambulatory Practice.”)

Additional Assistance

Contact our expert patient safety risk managers at (800) 421-2368 or by email for guidance and assistance in addressing any patient safety or risk management concerns.