What’s New in the Patient Safety World

October 2012

Monitoring During Procedural Sedation in Children

In our January 25, 2011 Patient Safety Tip of the Week “Procedural Sedation in Children” we mentioned the Pediatric Sedation Research Consortium (PSRC). That’s a large collaborative group of institutions doing sedation for procedures in pediatrics who have come together to share data and foster research. They now have accumulated data on over 100,000 children undergoing sedation for procedures outside the operating room (including procedures such as MRI scans, lumbar punctures, bone marrow biopsies, endoscopies, etc.).

While the overall rates of serious adverse events have been relatively low, a new study from the PSRC (Langhan 2012) shows wide variation in compliance with monitoring guidelines during procedural sedation. Guidelines published by the American Academy of Pediatrics, American College of Emergency Physicians, and American Society of Anesthesiologists were adhered to in only 52% of procedures.

They noted tremendous variability between specialties in the monitoring used. Of particular concern, radiologists used pulse oximetry in only a third of cases and did not use any monitoring in about 40% of cases.

We’ve done numerous articles (see the list at the end of this article) on radiology as a high risk area for a variety of reasons, many of which are not directly related to radiology. But procedural sedation is one of the areas directly related to radiology personnel. What’s compliance with monitoring like in your radiology department?

We hope you’ll look at our extensive discussion on procedural sedation in our January 25, 2011 Patient Safety Tip of the Week “Procedural Sedation in Children”.

Some of our prior columns on procedural sedation:

· May 25, 2010 “Propofol Issues”

· August 2012 “Sedation Costs for Pediatric MRI”

· January 25, 2011 “Procedural Sedation in Children”

· May 2011 “Update on Pediatric Procedural Sedation”

· August 2011 “NEJM Video on Conscious Sedation for Minor Procedures in Adults”

· October 2011 “The Procedural Sedation Debate Rages On”

· April 2012 “Problems with Ketofol”

Some of our prior columns on patient safety issues in the radiology suite:

· October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”

· September 16, 2008 “More on Radiology as a High Risk Area”

· October 7, 2008 “Lessons from Falls....from Rehab Medicine”

· January 2010 “Falls in the Radiology Suite”

· August 2010 “Sedation Costs for Pediatric MRI”

· January 25, 2011 “Procedural Sedation in Children”

· February 19, 2008 “MRI Safety”

• March 17, 2009 “More on MRI Safety”
• October 2008 “Preventing Infection in MRI”
• March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
• February 1, 2011 “MRI Safety Audit”
• October 25, 2011 “Renewed Focus on MRI Safety”
• March 13, 2012 “Medical Emergency Team Calls to Radiology”

References:

Langhan ML, Mallory M, Hertzog J, Lowrie L, Cravero J for the Pediatric Sedation Research Consortium. Physiologic Monitoring Practices During Pediatric Procedural Sedation. A Report From the Pediatric Sedation Research Consortium. Arch Pediatr Adolesc Med 2012; Published online September 10, 2012

http://archpedi.jamanetwork.com/article.aspx?articleid=1357757

http://www.patientsafetysolutions.com/

Home

Tip of the Week Archive

What’s New in the Patient Safety World Archive