COMEDY OF ERRORS With the Joan Rivers malpractice case settled, there are some key takeaways from the tragedy.

What lessons can we learn from the recently settled medical malpractice lawsuit against the clinic where Joan Rivers stopped breathing and died days after undergoing a routine endoscopy? The suit alleged that doctors at Yorkville Endoscopy performed unauthorized procedures, snapped a cell phone selfie with the comedienne and failed to act as her vital signs deteriorated. In a statement, Ms. Rivers's daughter, Melissa Rivers, said that she "will work towards ensuring higher safety standards in outpatient surgical clinics." Here are 5 key takeaways from the case.

Routine doesn't mean risk-free. The American Society of Anesthesiologists (ASA) reminds us that although anesthesia is now considered routine, that doesn't mean it is risk-free. "Any number of things can go wrong in the operating room," said ASA President Jane C. K. Fitch, MD. Whether you're in a fast-paced cataract clinic, an endoscopy suite or a standard OR, stress to staff and physicians to treat each case with extreme care and remain on guard to protect the patient.

Mistakes can be costly. The amount of the Rivers settlement wasn't disclosed, but lawyers confirmed that it was "substantial." This falls in line with what we know about non-hospital, anesthesia-related medical malpractice claims. One analysis of more than 3,300 closed claims in an ASA database shows that the median payment per claim is $210,000 for events occurring in the OR and $330,000 for claims occurring outside of the OR, including PACU or an endo suite (osmag.net/FadBW5). In claims involving areas outside of the OR, the study found that most took place in a gastrointestinal suite during monitored anesthesia care (32%). These numbers are a good reminder that not only can adverse events occur outside of the OR, but also that these incidents can trigger a costly lawsuit for your facility.

Follow highest standards of care. The standards of the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), the agency that accredited Yorkville Endoscopy, and the ASA differ in one key area that greatly impacted the Rivers case: what you're required to monitor. The AAAASF standard requires oxygen saturation monitoring by pulse oximetry, which provides a very late indicator of hypoventilation. ASA standards provide an extra level of safety by requiring you to monitor the adequacy of ventilation in addition to oxygenation. ASA standards call for the "continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide." Although you may be a clinician, thinking like a lawyer could keep you out of a lawsuit. If you were a lawyer defending an outpatient surgery center like the one Joan Rivers was stricken in, would you prefer that center to have used the AAAASF's standard or ASA's? (See "AAAASF Defends Anesthesia Monitoring Standards.")

Closely monitor sedated patients. The Rivers case highlights the importance of monitoring sedated patients. As a matter of policy, you should monitor the respiration rate, oxygen and sedation levels of all patients who receive any type of sedative, whether it's opioids in PACU after a knee replacement or propofol for an endoscopy. Inadequate monitoring for respiratory depression poses the greatest risk to patients, according to the ECRI Institute's 2016 Top 10 Patient Safety Concerns for Healthcare Organizations (osmag.net/S3FPff).

CMS recommends you closely monitor patients receiving opioids. In a recent guidance report (osmag.net/PurSW5), the organization notes that each year serious adverse events, including fatalities, are associated with the use of IV opioid medications in hospitals. These deaths "might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoring of the patient's respiration rate, oxygen and sedation levels." CMS also notes that patients receiving these drugs often are "placed in units where vital signs and other monitoring typically is not performed as frequently as in post-anesthesia recovery units."

Prepare and educate staff. One of the issues we learned from the initial documents filed in the Rivers case was that the center was not prepared for an emergency. There was said to be panic among the providers, and one even allegedly fled once she realized there was a serious issue. Every outpatient facility needs to have a protocol in place for handling respiratory and other emergencies.

This doesn't simply mean having a crash cart somewhere on location, though. Unless you have drilled for it and completely trained for it, it can be difficult to correctly implement in an emergency. Just having the equipment does not guarantee staff know how to use it and use it proficiently under stress. Instead, hold regular drills and education sessions for staff, and ensure that everyone knows what their role is in the event of an emergency.

Dealing with scrutiny
The death of a celebrity like Joan Rivers draws extra attention and substantial costs, both in terms of dollars and reputations lost. These simple precautions and lessons learned could save future lives and protect your facility from costly lawsuits. OSM