Minimising Risk in Procedural Sedation
I welcome the opportunity to read this article and thank the authors for their work which adds considerably to the literature on the topic of Procedural Sedation and Analgesia (PSA) in Emergency Departments (EDs).
My own experience is similar, and I concluded some time ago that complications, or situations where complications are more likely to occur, can be minimised by a system of training, education, and by changing department processes. Change included inserting multiple barriers preventing situations where the "Swiss Cheese Effect" occurs (1.) These barriers comprise steps where x cannot occur without y rather than a guideline or protocol which staff may easily bypass by choice.
We now have a situation where the Anaesthetic and Sedative drugs are locked and governed as Controlled Drugs (need to get keys from Shift Leader nurse, check drugs etc.), the patient must be formally admitted to ED - this involves approval from the duty ED Consultant, and the Shift co- ordinator (senior Nurse). Certain documents must be completed including a detailed Anaesthetic pre-assessment (this prompts consideration of medical history, airway anatomy, age, fasting status, etc.) Equipment checks must occur, the patient located in a Resus Bay. The nurses now have an embedded culture of completing these documents PRIOR to getting any drugs out of the cupboard. Fostering a department culture of questioning actions by all staff where potential harm is occurring contributes to the Safety atmosphere. Referring deviations from the process to the duty ED consultant is encouraged.
The single biggest (and most popular) step is the introduction of a Sedation Document pack including a Team-Time-Out checklist (see attached.) This demands a process of reflection, double checking, and sign-off prior to starting the Sedation.
However, I still struggle to see how I can prevent the index case prompting this revision: a surgeon removing a syringe of Propofol from the theatre Anaesthetic Room, walking into ED, and behind the curtain giving the lot IV, incising an abscess, then leaving without informing anyone...luckily an alert nurse went to see what he had done, rescued the apnoeic hypotensive victim, and no harm occurred.
1. Human Error: Models and Managment. Reason J. BMJ 2000; 320:768-70
Conflict of Interest: