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What’s New in the Patient Safety World

September 2019


·       New Guidelines for Pediatric Dental Sedation

·       Leapfrog’s Never Events Policy

·       Alarm Fatigue in the Emergency Room

·       New MRI Hazard: Magnetic Eyelashes



New Guidelines for Pediatric Dental Sedation



We’ve published multiple columns on the risks of sedation for dental procedures (see list below). The AAP (American Academy of Pediatrics) and the AAPD (American Academy of Pediatric Dentistry) recently updated their joint “Guideline for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures” (Cote 2019). This is a comprehensive guideline that notes how pediatric procedural sedation differs from that in adults and focuses on multiple facets of procedural sedation in pediatric patients:

-        no administration of sedating medication without the safety net of medical/dental supervision

-        careful pre-sedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications

-        appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure

-        a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction

-        a clear understanding of the medication’s pharmacokinetic and pharmacodynamic effects and drug interactions

-        appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access

-        appropriate medications and reversal agents

-        sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient

-        appropriate physiologic monitoring during and after the procedure

-        a properly equipped and staffed recovery area

-        recovery to the pre-sedation level of consciousness before discharge from medical/dental supervision

-        appropriate discharge instructions


The principles really apply to pediatric procedural sedation in a variety of settings and venues, but the purpose of this updated report was to unify the guidelines for sedation used by medical and dental practitioners and to add clarifications regarding monitoring modalities, particularly regarding continuous expired carbon dioxide measurement, and other refinements.


A group of 6 healthcare organizations has recently endorsed those new guidelines for pediatric dental sedation. The 6 include the American Academy of Pediatrics, the American Academy of Pediatric Dentistry (AAPD), the American Society of Anesthesiologists (ASA), the Society for Pediatric Anesthesia, the American Society of Dentist Anesthesiologists, and the Society for Pediatric Sedation.


Perhaps the most important item in the guideline is a requirement that such procedures be done in the presence of two qualified individuals. That means that the dentist or oral surgeon performing the dental or oral surgery procedure cannot be the individual administering and monitoring the sedation. This ensures that individuals are attending to one primary task and not involved in two different tasks simultaneously.


The guideline also clarifies that deep sedation or general anesthesia must be administered by a qualified anesthesia provider (a physician anesthesiologist, certified registered nurse anesthetist, dentist anesthesiologist or second oral surgeon). Because children commonly pass from an intended sedation level to an unintended deeper level of sedation, practitioners of sedation must have the skills to rescue the patient from a deeper level than that intended for the procedure. The ability to rescue means that practitioners must be able to recognize the various levels of sedation and have the skills and age- and size-appropriate equipment necessary to provide appropriate cardiopulmonary support if needed.


The guideline includes discussion on monitoring and documentation before, during, and after the procedure. There is good discussion on capnography for continuous expired carbon dioxide measurement.


The guideline also emphasizes caution, as we have in multiple columns, regarding the use of devices such as “papooses” that might restrict chest movement or obstruct airways.


We are also pleased to see the guideline emphasizes the need, for nonhospital facilities, for a protocol for the immediate activation of the EMS system for life threatening complications. We’ve previously advised that drills and simulations include even front office staff so they can facilitate such emergency responses.


There is far more in the updated guideline than we can fit is a short column. We encourage you to read the guideline in its entirely.



Some of our previous columns on dental patient safety issues:


March 15, 2016           “Dental Patient Safety

August 2016               “Guideline Update for Pediatric Sedation

March 28, 2017           “More Issues with Dental Sedation/Anesthesia

August 8, 2017           “Sedation for Pediatric MRI Rising

November 28, 2017    “More on Dental Sedation/Anesthesia Safety

July 2019                    “Dental Prescribing Called Into Question







Coté CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics 2019; 143(6): June 2019







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Leapfrog’s Never Events Policy



The Leapfrog Group’s “Never Event Policy” (Leapfrog Group 2019) calls on healthcare organizations to do the following when a never event has occurred in their facility/organization:

-        Apologize to the patient;

-        Report the event; 

-        Perform a root cause analysis; 

-        Waive costs directly related to the event; 

-        Provide a copy of the hospital’s policy on never events to patients and payors upon request.

-        Involve patients and families in the root cause analysis when willing and able to participate

-        Inform the patient and family of the action(s) that the hospital will take to prevent future recurrences of similar events based on the findings from the root cause analysis

-        Have a protocol in place to provide support for caregivers involved in never events, and make that protocol known to all caregivers and affiliated clinicians

-        Perform an annual review to ensure compliance with each element of Leapfrog’s Never Events Policy for each never event that occurred


The first 5 elements have been in place since 2007 but the last 4 items were added in 2017. There was some drop off in hospital compliance with the standards after the 4 latter elements were added. Overall, about 75% of both teaching and non-teaching hospitals most recently have met all the standards.


The Leapfrog report mentions a couple key resources to aid organizations comply with the standards: the AHRQ’s CANDOR toolkit (see our June 2016 What's New in the Patient Safety World column       “Disclosure and Apology: The CANDOR Toolkit”) and the NPSF RCA2 tool (see our July 14, 2015 Patient Safety Tip of the Week “NPSF’s RCA2 Guidelines”).



Some of our prior columns on Disclosure & Apology:

July 24, 2007              “Serious Incident Response Checklist

June 16, 2009              “Disclosing Errors That Affect Multiple Patients

June 22, 2010              “Disclosure and Apology: How to Do It

September 2010          “Followup to Our Disclosure and Apology Tip of the Week

November 2010          “IHI: Respectful Management of Serious Clinical Adverse Events

April 2012                   “Error Disclosure by Surgeons

June 2012                    “Oregon Adverse Event Disclosure Guide

December 17, 2013     “The Second Victim

July 14, 2015              “NPSF’s RCA2 Guidelines

June 2016                    “Disclosure and Apology: The CANDOR Toolkit

August 9, 2016           “More on the Second Victim

January 3, 2017           “What’s Happening to “I’m Sorry”?

October 2017              “More Support for Disclosure and Apology

April 2018                   “More Support for Communication and Resolution Programs

August 13, 2019         “Betsy Lehman Center Report on Medical Error




Other very valuable resources on disclosure and apology:





Some of our prior columns on RCA’s, FMEA’s, response to serious incidents, etc:


July 24, 2007              “Serious Incident Response Checklist

March 30, 2010           “Publicly Released RCA’s: Everyone Learns from Them

April 2010                   “RCA: Epidural Solution Infused Intravenously

March 27, 2012           “Action Plan Strength in RCA’s

March 2014                 “FMEA to Avoid Breastmilk Mixups

July 14, 2015              “NPSF’s RCA2 Guidelines

July 12, 2016              “Forget Brexit – Brits Bash the RCA!

May 23, 2017              “Trolling the RCA







Leapfrog Group. Never Events Report. 2019






Print “September 2019 Leapfrog’s Never Events Policy





Alarm Fatigue in the Emergency Room



We’ve done many columns on alarm fatigue and alarm management (see full list below) but the focus has been in ICU’s, med/surg units, and the OR. One venue largely ignored has been the emergency room.


Now a new study (Fleischman 2019) has analyzed alarms in the emergency department and confirmed that, like in all other venues, many alarms are clinically irrelevant and only contribute to the problem of alarm fatigue. The study was based on 53 hours of observation by an ED physician and recorded patient characteristics, alarm type, staff response, whether the alarm was likely real or false, and whether it changed clinical management. There was a median of 18 alarms per hour of observation, and the median number of alarms per patient was 4. Amazingly, alarms changed clinical management in only 8 out of 1049 observed alarms (0.8%) and in 5 out of the 146 patients (3%). Moreover, staff did not observably respond to most alarms (63%).


The authors suggest that efforts at improving the clinical significance of alarms could focus on widening alarm thresholds, customizing alarms parameters for patients' clinical status, and on utilizing monitoring more selectively.



Prior Patient Safety Tips of the Week pertaining to alarm-related issues:







Fleischman, William et al. Emergency department monitor alarms rarely change clinical management: An observational study. The American Journal of Emergency Medicine 2019; Published online July 30, 2019





Print “September 2019 Alarm Fatigue in the Emergency Room





New MRI Hazard: Magnetic Eyelashes



Prior to performance of magnetic resonance imaging patients are screened for the presence of metallic or ferromagnetic items that might be safety hazards because they can migrate in the presence of a strong magnetic field or become heated and result in burns. They may also produce artifacts that interfere with interpretation of studies. Still other devices might malfunction under exposure to the magnetic field.


Typical items screened for are jewelry, pacemakers, clips, implanted pumps, electrodes, wires, medication patches, and many others. But some more unusual items have received attention. In our April 2, 2019 Patient Safety Tip of the Week “Unexpected Events During MRI” we discussed tattoos, which may be made with color pigments containing ferrous particles that may interact with the magnetic resonance, potentially leading to burns.


Now here’s another new one: magnetic eyelashes! Magnetic eyelashes are a relatively new cosmetic product. Researchers recently used a phantom to study possible role that magnetic eyelashes might have in producing MRI image artifact (Slonimsky 2019). They found that the eyelashes could produce artifacts and reduce image quality, in addition to being pulled off by the magnetic field. In fact, the artifact created from the magnetic eyelashes was significantly larger than the distortions created by some aneurysm clips.


The researchers did not assess the risk of heating on these eyelashes because they were using a phantom. However, the reason they chose to study this on a phantom rather than a human volunteer was that they were concerned the eyelashes could heat significantly and cause burns.


The authors strongly recommend inserting a line about magnetic eyelashes on the MRI safety questionnaire and adding stops in the screening system to prevent the entry of anyone with these lashes, including staff, into the MRI scanner room.



Some of our prior columns on patient safety issues related to MRI:






Slonimsky E, Mamourian A. Magnetic Eyelashes: A New Source of MRI Artifacts. American Journal of Roentgenology 2019;: 1-3 Posted online on 24 Jul 2019.





Print “September 2019 New MRI Hazard: Magnetic Eyelashes




Print “September 2019 What's New in the Patient Safety World (full column)

Print “September 2019 New Guidelines for Pediatric Dental Sedation

Print “September 2019 Leapfrog’s Never Events Policy

Print “September 2019 Alarm Fatigue in the Emergency Room

Print “September 2019 New MRI Hazard: Magnetic Eyelashes



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