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the quality and safety of an outpatient center. The media has posed more ques-
tions about the safety of centers than it has answered. But there is a potential
positive from the increased attention. It may be a wake-up call for some centers
to re-evaluate their policies and practices.
• What will you discuss about the case? I'll review the known facts from the report
issued by the Department of Health and Human Services as well as accusations
from the lawsuit filed by Joan's daughter, Melissa. Why was the vocal cord biop-
sy performed? Did an uncredentialed ENT provider perform the procedure?
Was there an anesthesiologist in the room? Did Ms. Rivers's personal doctor
take an inappropriate "selfie" during the case? These are the key points we'll
discuss.
• Lessons for us all. All facilities can learn lessons from the incident. There are
potential pitfalls to caring for VIPs. And although having appropriate equipment
is a prerequisite, the need for regular drills for treating uncommon crises cannot
be overemphasized. We'll discuss the benefits of operationalizing a crisis man-
agement checklist for the medical complications most likely to occur in the out-
patient setting.
• What barriers do facilities continue to face when ensuring patient safety?
Some of most common safety risks are cultural. When there is low psychologi-
cal safety, nurses and anesthesia providers may not speak up. There's also a lack
of training and drilling for complications. Potential solutions include expanded
checklist adoption and regular team training. Even more basic precautions
involve an organizational infrastructure that includes respectful communication
and a just culture, meaning individuals aren't punished for human error, but are
held accountable for decisions.
