While the death of comedian Joan Rivers at an outpatient surgery center in 2014 may have shocked the public, it was no surprise to many attorneys familiar with medical negligence cases. Center violations found during the Rivers investigation, including failure to notice deteriorating vitals, a discrepancy in the medical record concerning anesthesia dosage received, and performance of the procedure by a non-credentialed doctor, represent a larger trend that many of us have been observing for years now.[1] So, what exactly is happening in these centers and why? How can risk factors be identified and reduced?  This post will explore these questions in the hopes of providing some answers.


What are surgery centers and what danger do they pose?

Outpatient surgery centers first emerged about 50 years ago as low-cost alternatives to hospitals for minor surgical procedures.[2] A combination of improved perioperative care and economic pressure has driven many would-be hospital patients to opt for outpatient surgical procedures at the growing number of centers across the country.[3] Despite the fact that most operations done in these centers are successful, a recent investigation by Kaiser Health News and USA Today has revealed that over the past five years, at least 260 people have died during procedures in these settings and thousands of 911 calls have been placed when complications the center is not prepared to deal with arise.[4]


Why is this happening?

As the investigation mentioned above revealed, outpatient surgery centers have been progressively expanding their business by increasing the number of risky surgeries performed.[5] This is partially due to the fact that while hospitals are tightly regulated, surgery centers largely operate under a variety of typically less strict state laws,[6] and they are typically owned by doctors who have financial incentive to recommend their patients undergo procedures at their clinic instead of a hospital.[7] The Kaiser Health and USA Today team also found that some surgery centers have been accused of skimping on training and overlooking high-risk health problems that experts say need the attention of a hospital.[8] As a consequence, and often due to infection, bleeding, and impaired healing, one study determined that about 1 in 1,000 patients develop a complication that is serious enough to warrant hospital transfer during or immediately after a procedure.[9]


Which patients are at the highest risk?

Though the general lapses in safety mentioned above affect all potential patients, multiple studies have established that there are certain conditions that put some at a particularly high risk when undergoing a procedure at an outpatient surgery centers. Here is a list of risk factors for morbidity or mortality identified by a few key studies:[10]

  • Overweight body mass index
  • Obese body mass index
  • Chronic obstructive pulmonary disease
  • History of transient ischemic attack (“mini-stroke”) or stroke
  • Hypertension
  • Previous cardiac surgical intervention
  • Prolonged operative time
  • Diabetes
  • Female sex
  • Smoking status
  • Coronary artery disease
  • Peripheral vascular diseases

Additionally, while older age was not found specifically to be associated with adverse outcomes in outpatient surgeries, many comorbidities listed above are present in older patients, therefore increasing their operative and postoperative risks.[11]


While all surgeries pose risk, hospitals are generally better equipped to handle errors or complications that may arise.[12] However, more than two-thirds of operations performed in the United States now occur in outpatient centers, and in 2011, 23 million procedures were performed in surgery centers, showing that these institutions are clearly here to stay.[13] Therefore, it is critical to demand stricter regulations to ensure proper staff training, equipment, documentation, and motivations for center owners, and recognize which individuals are better off having surgery performed in a hospital setting.


Just knowing what the risks are for increased morbidity and mortality might not be enough for you to understand if there was medical negligence. Our nurses are skilled at chart review and analysis in surgery cases, whether inpatient, outpatient or surgery center cases. Our efficiency can make a difference in your practice and help you understand how you want and need to proceed with these incredibly tragic cases.

[1] Boodman, Sandra, B. “Popularity of Outpatient Surgery Centers Leads to Questions About Safety,” Medscape, Dec. 29, 2014, https://www.medscape.com/viewarticle/837298

[2] Jewitt, Christina & Mark Alesia, “How a push to cut costs and boost profits at surgery centers led to a trial of death,” USA Today, March 2, 2018, https://www.usatoday.com/story/news/2018/03/02/medicare-certified-surgery-centers-safety-deaths/363172002/

[3] Mathis, Micahel R., Naughton, Norah N., Shanks, Amy M., Freundlich, Robert E., Pannucci, Christopher J., …et al., “Patient Selection for Day Case-Eligible Surgery: Identifying Those at High Risk for Major Complications,” Anesthesiology, 2013, 12(119), http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1918045

[4] Jewitt & Alesia, “How a push to cut costs”

[5] Ibid

[6] Boodman, “Popularity of Outpatient Surgery”

[7] Fletcher, Ram, “Medical Malpractice in Ambulatory Surgery Centers,” Bohn & Fletcher Law, June 7, 2016, https://www.bohnlaw.com/2016/06/07/medical-malpractice-ambulatory-surgery-centers/

[8] Jewitt & Alesia, “How a push to cut costs”

[9] Boodman, “Popularity of Outpatient Surgery”; Goldfarb, C.A., Bansal, A., & R. H. Brophy, “Ambulatory Surgical Centers: A Review of Complications and Adverse Events,” National Center for Biotechnology Information, Jan. 25, 2007, https://www.ncbi.nlm.nih.gov/pubmed/28002212

[10] Mathis, et. al, ““Patient Selection for Day Case-Eligible Surgery”; Goldfarb, Bansal, & Brophy, “Ambulatory Surgical Centers”; Kent, C., Metzner, J., & L. Bollag, ”An Analysis of Risk Factors and Adverse Events in Ambulatory Surgery,” Dove Press, April 2., 2014, https://www.dovepress.com/an-analysis-of-risk-factors-and-adverse-events-in-ambulatory-surgery-peer-reviewed-fulltext-article-AA

[11] Kent, Metzner, & Bollag, ”An Analysis of Risk Factors”

[12] Fletcher, “Medical Malpractice”

[13] Boodman, “Popularity of Outpatient Surgery”