Improving Patient Safety by Understanding Past Experiences in Day Surgery and PACU

Patient safety is a priority, yet little is understood regarding the nature of errors in the perianesthesia settings. The purpose of this claims analysis was to examine patient safety issues in the day surgery and PACU. A retrospective, exploratory design was used. Ninety-three patient safety cases were identified. Differences emerged between PACU and day surgery in regard to allegations and risk management issues. Thirty-nine percent of PACU and 25% of day surgery cases involved nurses as the primary responsible party. The top three risk management issues related to PACU nurses were clinical judgment (24%), administrative (19%), and communication (19%) issues. The top three risk management issues identified in the day surgery unit were administrative (27%), behavior-factors with patient compliance (18%), and clinical judgment issues (18%). The information gathered in this analysis can provide an impetus for units to examine their practices, organizationally and individually.

Keywords: patient safety, risk management, day surgery, PACU, ambulatory surgery, legal issues