PA PSRS Patient Saf Advis 2007 Sep;4(3):104.
Deaths Following Ambulatory Surgery
Emergency Medicine; Gastroenterology; Surgery
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The Centers for Medicare & Medicaid Services (CMS) are revising their criteria for services that can be performed in ambulatory surgical facilities (ASFs).1 This prompted us to look at PA-PSRS reports of death following ambulatory surgical facility procedures. We found the following 10 reports:


Patient A: An elderly patient had a colonoscopy for rectal bleeding.  The procedure was complicated by a perforation of the colon. The patient was transferred to a hospital, underwent surgical correction, and died following postoperative complications.

Patient B: An elderly patient had a cardiopulmonary arrest while receiving postoperative discharge instructions after an unspecified procedure. The patient was resuscitated and transferred to a hospital, but died there. 


Patient C: An elderly patient had an upper gastrointestinal (GI) endoscopy with dilation. Several days later, the patient had upper GI bleeding, was admitted to the hospital and appropriately treated, but died.

Patient D: An elderly patient had an uneventful screening colonoscopy and was discharged in stable condition. The patient was found dead at home the next day. The cause of death was listed as “natural causes.”

Patient E: A young adult vomited during an upper GI endoscopy, aspirated the emesis, was intubated, was transferred to a hospital, and subsequently died.

Patient F: A middle-aged patient had a cardiopulmonary arrest during a retrobulbar block for eye surgery.  The patient was intubated, transferred to a hospital in unstable condition, and died.

Patient G: A young adult had an apparently routine tonsillectomy. The patient was found unresponsive later that day at home; resuscitation efforts were not successful. The autopsy showed no gross pathology.


Patient H: An elderly patient had uneventful eye surgery. The patient died at home later that day after complaining of not feeling well.

Patient I: An elderly patient had a respiratory arrest at the end of a procedure. The patient was intubated, transferred to a hospital, and subsequently died.

Patient J: A middle-aged patient had respiratory distress during the recovery period after a procedure.  The patient required re-intubation, but progressed to cardiac arrest.  The patient was transferred to a hospital in unstable condition and died.

We note that it is not the procedure itself that is the emergency, but the complication. In this cohort, the common factors that were identifiable were either pre-existing co-morbid medical conditions that produced cardiopulmonary arrest or problems with ventilation. These experiences underscore the importance of ASFs having the capacity to respond to predictable emergency conditions.  In addition to the obvious—cardiopulmonary arrest, problems managing the airway, dysrythmias, and bleeding—air embolus and malignant hyperthermia are more unusual problems that could theoretically occur in the ASF setting. As previously noted, the capacity of ASFs to respond to emergencies includes established transfer agreements with hospitals.2


  1. Centers for Medicare & Medicaid Services. 42 CFR parts 410, 414, et al. Medicare: hospital outpatient prospective payment system and CY 2007 payment rates; proposed rule. Fed Regist 2006 Aug 23;71(163):49636-46.
  2. Pennsylvania Patient Safety Reporting System. Expecting the unexpected: ambulatory surgical facilities and unanticipated care. PA PSRS Patient Saf Advis 2005 Sep;2(3):6-8.

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