Hospital's Lax PACU Policies Cited
Inside the Morphine Overdose Deaths of Two Boys
SouthCrest Hospital in Tulsa, Okla., violated state and federal laws and ignored accepted standards of practice when it gave two boys lethal overdoses of morphine, officials said. The boys, ages 3 and 6, died eight days apart in October. They were released after seemingly uneventful procedures in the hospital's outpatient surgery center, only to be found unresponsive hours later at home from what the medical examiner concluded were accidental morphine overdoses.

An investigation conducted by the Oklahoma State Department of Health found that the hospital lacked approved policies for giving medicine in the PACU and didn't require a doctor's order specifying the drug, its dosage and how it should be administered, leaving PACU nurses to decide for themselves whether to administer IV morphine or Demerol without knowing the maximum doses for either drug, says Dean Bay, the state Department of Health's director of facility services.

Investigators also found that anesthesiologists didn't evaluate patients recovering from anesthesia, says Mr. Bay.

"I think it's frightening. I can't imagine practicing like that," says Anne Halliday, RN, BSN, CPAN, a staff nurse at Caritas St. Elizabeth's Medical Center in Boston. "There should be no guesswork in standing orders."

Ms. Halliday also questions the decision to give morphine to patients who are going home. "If they're having that much pain," she says, "admit them."

Nicholas Marlow, 6, died Oct. 3, two days after an outpatient surgery on his toenails, according to an autopsy report. Records show that he received 16mg of morphine. His maximum morphine dosage in PACU according to 0.3mg/kg every two hours would be 11.7mg.

Steven Tyler Verdin, 3, died Oct. 11, the morning after he had a tonsillectomy with adenoidectomy and bilateral myringotomy, according to an autopsy report. Records show that he was given versed and acetaminophen before the surgery and 4mg of morphine sulfate along with a single 5ml unit dose of acetaminophen with codeine elixir, and amoxicillin. His maximum morphine dosage in PACU according to 0.3mg/kg every two hours would be 4.2mg.

The hospital's post-anesthesia standing orders form had spaces for the physician to choose either IV morphine or Demerol or oral administration Tylenol with Codeine Elixir or Tylenol Elixir. The physician didn't specify which medication was to be administered for either boy, investigators found.

Since the November investigation, the state health department says the hospital has corrected the problems by revising the standing orders for pediatric outpatient surgeries to clarify drug dosage and route. "We have been undergoing a thorough review of policies and standing orders throughout the hospital and are making revisions as appropriate to each situation," says a hospital spokeswoman.

SouthCrest Hospital opened May 3, 1999. In 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) gave SouthCrest its worst score for problems prescribing, preparing, dispensing and administering drugs. JCAHO is reviewing the hospital again after the deaths of the boys, says spokesman Mark Forstneger. "The Joint Commission will review the organization's root cause analysis to ensure that it is thorough and credible," says Mr. Forstneger.

- Dan O'Connor

Inside The Numbers
Community Hospital Expansion

• 92% - Percentage of surveyed senior hospital executives who report it's either "very likely" or "somewhat likely" their hospital will undergo major expansion within three years
• 89% - Percentage of executives at hospitals with capital budgets of more than $5 million who say short-term expansion is very likely
• 26% - Percentage of respondents who listed maintaining current quality of care as a primary reason for expansion
• 25% - Percentage of respondents who rated reducing case costs as a primary reason for expansion

Source: Bayer Consulting and Turner Construction hospital executive survey (n=200)

2004 ASC Facility Fees
The Centers for Medicare and Medicaid Services (CMS) announced the updated ASC Medicare facility fee schedule, effective April 1.
Group 1 $333
Group 2 $446
Group 3 $510
Group 4 $630
Group 5 $717
Group 6 $676 (plus $150 for IOLs)
Group 7 $995
Group 8 $823 (plus $150 for IOLs)
Group 9 $1,339

ASCs Are Not Specialty Hospitals
AAASC Subtly Reminds MedPAC that Physician-owned ASCs Are Exempt from Stark
Just so MedPAC commissioners don't bring the same arguments against ambulatory surgery centers (ASCs) that they brought against surgical hospitals, the American Association of Ambulatory Surgery Centers (AAASC) last month fired off a fact-filled letter to members of the Medicare advisory panel that details why federal antikickback laws and Stark law prohibitions against physician self-referrals don't apply to physician-owned ASCs.

The letter, penned by AAASC President David Shapiro, MD, comes in the wake of a Jan. 15 MedPAC meeting in which one commissioner questioned payments to ASCs with physician ownership. That meeting initiated an 18-month moratorium imposed by Congress on Medicare payments to physicians for procedures in new surgical hospitals in which those physicians have ownership interests.

Dr. Shapiro's letter points out that CMS and Congress exempted ASCs from the Stark laws "because there is no perceived risk of abuse" with ASCs. He also notes a final rule published by the HHS Office of Inspector General specifying safe harbors under the anti-kickback statute for ASC investments.

- Dan O'Connor

National Wrong-Site Surgery Protocol
Operative-Site Marking Products Help You Comply
There's no shortage of products to help you comply with the universal protocol for preventing wrong-site, wrong-procedure and wrong-person surgery. To the right is a sampling of five operative-site marking products - stickers, a tattoo and a marker.

Compliance with the national wrong-site surgery protocol becomes effective July 1, when it will be required for all hospitals, ambulatory surgery centers and office-based surgery sites accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The protocol was established to standardize pre-surgery procedures for verifying the correct patient, the correct procedure and the correct surgical site. It focuses on marking the surgical site, involving the patient in that process and utilizing a procedure for taking a final time out in the OR so that all the members of the surgical team can double check information and ask questions.

"Safety is a progressive goal that will always compel change and adaptation," says Colby Manufacturing Marketing Manager Irene Tomchik. "There is always room for additional safety precautions, and healthcare facilities should be looking for ways to improve safety. More is better. The more redundant and repetitive the process, the better the outcome."

Wrong-site surgery accounts for more than one-third of sentinel events in ambulatory surgery centers, making it the most commonly reported sentinel event in the ASC setting, according to a recent JCAHO study. We've compiled a few products that may help your facility comply with site-verification requirements.

- Kristin Royer