Cancellations and Transfers Related to New-Onset Atrial Fibrillation: An Analysis of Survey and Patient Safety Reporting Data From Ambulatory Surgical Facilities


  • Lea Anne Gardner, PhD, RN Patient Safety Authority
  • Rebecca Jones, MBA, RN Patient Safety Authority
  • Melanie Motts, MEd, RN Patient Safety Authority



atrial fibrillation, cancellations, transfers, colonoscopy, endoscopy, patient safety


Visual abstract for af cancellations analysis article.

Atrial fibrillation (AF) is a cardiac arrhythmia characterized by an irregular rhythm and often rapid heart rate. People with AF can be symptomatic or asymptomatic and are at increased risk for stroke. In this study, we used two data sources—a survey and Pennsylvania Patient Safety Reporting System (PA-PSRS) reports—to examine new-onset AF in Pennsylvania ambulatory surgical facilities (ASFs). The survey was developed and conducted to learn more about new-onset AF–related cancellations and transfers in Pennsylvania ASFs and to update the Patient Safety Authority ASF Cancellation and Transfer Tracking Tool. The survey response rate was 53.1%, with 50.9% of respondents indicating new-onset AF–related cancellations in the last year. A five-year review of PA-PSRS data revealed an increase in the number of new-onset AF–related cancellation and transfer events that occurred in the last two years. In 70.9% of the reports, patients were 65 years of age and older. A paucity of research on this patient safety issue led us to identify areas for future research.

Author Biographies

Lea Anne Gardner, PhD, RN, Patient Safety Authority

Lea Anne Gardner ( is a patient safety analyst with the Patient Safety Authority. She has more than 30 years of research experience in patient safety, performance improvement, cardiology, and behavioral health. She has served as a national director of nursing, quality improvement, and population health, and an administrative director of an institutional review board. Gardner is also a Certified Professional in Patient Safety (CPPS).

Rebecca Jones, MBA, RN, Patient Safety Authority

Rebecca Jones is director of Data Science and Research at the Patient Safety Authority, where she also founded and serves as director of the Center of Excellence for Improving Diagnosis. Her previous roles at the PSA include director of Innovation and Strategic Partnerships, and regional patient safety liaison. Before joining the PSA, Jones served in various roles leading patient safety efforts and proactively managing risk in healthcare organizations. She currently is chair of the Practice Committee of the Society to Improve Diagnosis in Medicine and serves on the Advisory Committee of the Coalition to Improve Diagnosis.

Melanie Motts, MEd, RN, Patient Safety Authority

Melanie Motts is a senior patient safety liaison with the Patient Safety Authority for the Eastern region of Pennsylvania. Before joining the Authority in 2015 she worked in various leadership roles in outpatient and inpatient settings as a director of nursing, patient safety officer, manager, educator, and registered nurse. Motts is also a Certified Professional in Patient Safety (CPPS).


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How to Cite

Gardner, L. A., Jones, R. ., & Motts, M. (2021). Cancellations and Transfers Related to New-Onset Atrial Fibrillation: An Analysis of Survey and Patient Safety Reporting Data From Ambulatory Surgical Facilities. Patient Safety, 3(4), 28–38.



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