Preventing Harm During Moderate Procedural Sedation

A recent article in The Joint Commission Journal on Quality and Patient Safety finds that “certain patient characteristics and types of procedures may be associated with increased risk of [adverse events] during [moderate procedural sedation].” Characteristics associated with increased risk included gender (women were more at risk), advanced age, and malignancy and cardiovascular comorbidities. The specialties most frequently associated with increased risk were cardiology, gastroenterology, and radiology.

What The Joint Commission’s article doesn’t address is prevention.

What You Can Do: Learning from Oregon Prevention Strategies

We looked to Oregon’s Patient Safety Reporting Program (PSRP) data to learn what Oregon facilities are doing to prevent adverse events during moderate procedural sedation. Specifically, we examined prevention strategies for two of the most common adverse events related to moderate procedural sedation identified in The Joint Commission’s article—oversedation and aspiration. Here are some of the strong prevention strategies implemented by Oregon facilities that may help your facility to prevent these types of adverse events.

Standardize, standardize, standardize!

Oregon facilities identified variation across services in hand-off procedures, patient assessment, and patient management as causes of events involving moderate procedural sedation. Their strong prevention strategies included:

• Standardize hand-off procedures across all services

• Standardize management of patients receiving moderate sedation across services, including use of screening tools

What You’ll Need

TeamStepps: Strategies & Tools to Enhance Performance and Patient Safety
Agency for Healthcare Research and Quality
Breakdowns in communication are one of the top factors contributing to adverse events. This pocket guide is a highly-valued resource for ensuring effective communication. The following tools in the guide can help you to standardize handoff communication, consider the following tools in the guide: Situation, Background, Assessment, Recommendation (SBAR); Handoff; and I Pass the Baton.

STOP-BANG Patient Questionnaire
Oregon Patient Safety Commission
A standardized screening tool, such as STOP-BANG, can help you identify patients at risk of oversedation. Note: A patient’s STOP-BANG score is only one of a number of considerations in the pre-surgical evaluation of patient risk. Learn more in our Statement on Preventing Harm from Oversedation.

Prevent making the wrong choice with forcing functions.

The strongest prevention plans are those that remove the possibility for human error. Oregon facilities identified medication ordering and dosing as opportunities to integrate forcing functions into their equipment and electronic health records. Their strategies included:

• Program all scales in the facility to weigh patients in metric for safer, weight-based dosing

• Program electronic health records to limit the amount of certain types of medications that providers can order for a procedure. Standardized and simplified order sets can decrease variability and increase the likelihood of safe dosing.

What You’ll Need

Human Factors: Prevention and Improvement Strategies Matrix
Oregon Patient Safety Commission
The Institute for Healthcare Improvement defines human factors as “the study of all factors that make it easier to do work in the right way.” When you apply human factors principles during an adverse event investigation and analysis, they can help your team identify strong strategies to improve patient safety.

Get leadership support.

Oregon facilities identified the critical need for leadership support to set organizational priorities and allocate resources. Some of the ways they planned to do this included:

• Immediately escalate adverse events to senior leadership

• Senior leadership participate in rounds to emphasize use of tools for a high reliability organization

What You’ll Need

Stop the Line
Leadership in your organization can create a system to empower employees to speak up immediately if they see a risk to patient safety. Any employee that “stops the line” is protected from retribution, creating a culture where learning and improvement are possible.

What have you done to address this or similar safety risks? Share what you’ve learned in your organization and contribute to the ongoing learning about adverse events in Oregon through the Patient Safety Reporting Program.

References

Jones, Mark R., Sergey Karamnov, and Richard D. Urman. “Characteristics of Reported Adverse Events During Moderate Procedural Sedation: An Update.” Joint Commission Journal on Quality and Patient Safety 44, no. 11 (November 1, 2018): 651–62. https://doi.org/10.1016/j.jcjq.2018.03.011.