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Advancing a Safety Culture in
the Care of Sedated Children:
Nursing Issues
Terri Voepel-Lewis, MSN, RN
University of Michigan Health Systems
Examples of High Risk/High Safety

Airline industry

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Anesthesiology

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ASA Standards
Operating Room Nursing

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FAA Standards
AORN Standards
Sedation settings?

AAP Sedation Guidelines
The Top Five Indications that
Things are Amiss. . .
 5.
The practitioner complains that the pulse
ox is an unnecessary stimulus that may
prevent completion of the procedure.
 4.
An oximeter and its alarm are
considered sufficient replacement coverage
for competent, licensed personnel.
The Top Five Indications that
Things are Amiss. . .
 3.
A “healthy” dose (i.e., a “little extra”) of
chloral hydrate is considered a bonus in
the available repertoire to speed up the
start of the procedure.
 2.
The nurse considers baby formula to
be adjuvant sedative therapy to facilitate
completion of the procedure.
The Number One Indication that
Things are Amiss. . .
 1.
A crash course in airway management
techniques is included in the discharge
instructions to parents.
Case Report 1
4
year old ASA 1
 Presenting for MRI
 Chloral hydrate 75 mg/kg
 Paradoxical reaction in 10-15 mins
 Procedure aborted at 30 mins
 Child discharged to home 40 mins after CH
Case Report 1
 On
arrival at home (30 mins), child difficult
to arouse, unable to support his head
 Return to ED
 Monitored for 4 hours
 Discharged home without sequela
Case Report 1 - Factors
Contributing to Adverse Event
Discussion
Case Report 2
3
year old ASA 1 with hx of hematemesis
 Sedated for esophagoscopy
 Propofol induction 2 mg/kg

Infusion 6-9 mg/kg/hr
 Trained
pediatric resident and RN in
attendance
Case Report 2

Patient “deeply sedated”

No reflex withdrawal

Laryngospasm on insertion of endoscope
 Emergency measures initiated

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
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
BVM with PAP
Deepened level of sedation
Epinephrine
IV Corticosteroids
Laryngospasm prolonged (>5 mins)
 Call to Emergency anesthesia backup
Case Report 2
 Emergency
backup arrived
 Symptoms “almost completely resolved by
the time emergency team arrived”
 Total duration of event 9 minutes
 Outcome unknown
Case Report 2 - Factors
Contributing to Adverse Event
Discussion
Case Report 3
4
year old ASA 1 boy
 MRI for benign tumor below knee
 Previous uneventful sedation with
midazolam and fentanyl
 Mom requested oral sedative for IV start
at current visit
Case Report 3
Sedation Regimen
 Versed PO – 0.5 mg/kg
 30 minutes later
 Pentobarb IV – 3 mg/kg
 4 minutes later
 Fentanyl IV – 3 mcg/kg
 No pulse oximeter until mother said child did
not look right!!
 11 minutes later – no respirations, no pulse
Case Report 3 - Outcomes
 Documented
arrest time 10-12 minutes
 Decerebrate posturing on discharge
 2 years following event





standing with assistance
beginning to track
relearning to swallow
no communication
G-tube
Case Report 3 – Factors
Contributing to Poor Outcome
Discussion
“Probability of an Accident is
never Absolutely Zero”
Complexity of Patient
+
High Technology
+
Multiple Teams/Personnel
+
Different Settings
>
↑
Unpredictability
↑ Failure Modes
Promoting a Culture of Safety
AAP & AAPD Guidelines 1985

AAP Guidelines 1992

JCAHO Single standard of care 1994

ASA Practice Guidelines 1996

ASA Defines Sedation Continuum 1999

JCAHO Sedation/Anesthesia standards 2001

AAP Addendum 2002
Promoting a Culture of Safety

Improve system (leads to prevention of error)

Identify care that works (safe & efficacious)
• Standards of Care
• Protocols


Ensure that the patient receives that care
Deliver that care flawlessly
 Standardization
• Equipment & monitors
• Techniques and procedures
• Use of protocols/checklists
Promoting a Culture of Safety
 Simplification

Remove unneeded dangerous alternatives
Training and expertise
 Never violate the systems that have
been put into place.
Production Pressure
 As
the number of procedures increases,
so does the likelihood of error.
Advanced Safety Culture
Resolves conflict between production
pressure and safety.
Advanced Safety Culture





Informed at all levels
Seeks out information (what helps to ensure that
incidents do not turn into worse accidents)
Exhibits trust by all
Adaptable to change / Flexible
Worries
“Success does not engender complacency”
Assessment of Quality
 Structure Indicators
• (i.e., numbers, preparation, qualifications of staff, patient
population, settings)
• Provides the foundation of understanding process of care
 Process indicators


Outcome indicators


Way care is delivered
Results of work
Quality indicators

Quantitative measures to monitor & evaluate
important clinical activities.
Quality Indicators for Sedation
Activity
Possible indicators
Type
Airway
assessment
▪ Assessment completed
▪ Anesthesia consult as appropriate
Process
Supplemental
oxygen
▪ Supplemental oxygen immediately
available
Structure
Pulse oximetry
▪ Occurrence of O2 desaturation
>10%
Outcome
Adverse Events Reporting

Reporting structure and process problems



Unsafe acts
Unsafe conditions
Reporting outcomes

Sentinel Events
• Death
• Unexpected Hospital or ICU admission

“Near misses”
• Non-reportable by JCAHO standards
• “Safety Net” – AORN national database

Responding

Organized and systematic in managing hazards
Current Nursing Issues
 Competency




and training
BCLS
PALS?
Airway management techniques
IV access
 Pre-procedure
assessment &
planning



Oversight
Patient selection criteria
Use of medication guidelines
Current Nursing Issues
 Monitoring





and assessment
Depth of sedation
VS and BP monitoring
Pulse oximetry
End-tidal CO2 monitoring?
Use of supplemental O2?
Current Nursing Issues
 Children
at risk for sedation failure
 Difficult sedations



Agitation & paradoxical reactions
Supplemental sedatives (titration)
Sedation failures
• When to reschedule for sedation
• When to schedule general anesthesia
• When to discharge the patient

Use of reversal agents
Current Nursing Issues
 Sedation
Program discussion
 Institutional support and direction
 Oversight
 Available resources
 Recovery & discharge
Current Nursing Issues
 JCAHO

Review
Citations
 Quality Assurance
 Events
reporting
 Adverse events follow-up
 “The
COD has concluded that the
guidelines apply in all locations and to all
practitioners who care for children.”
 “Regardless
of the medications selected or
the route of administration, the potential
for serious adverse effects exists.”
• AAP Addendum Pediatrics 2002;110:836
Future Work to be Done

Newer sedation regimens

Drugs with increased margin of safety

Prevention/treatment of paradoxical reaction

Precise tests of discharge readiness

Consistent implementation of guidelines

Enhanced skill levels of sedation providers