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A A Case Rep. 2016 Mar 15;6(6):163-71. doi: 10.1213/XAA.0000000000000249.

From Root Cause to Action Plan: How an Adverse Event Uncovered Deficiencies in Resident Knowledge of Sedation Policies and Practices.

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From the *Department of Anesthesiology and Critical Care, Perelman School of Medicine; †Leonard Davis Institute of Health Economics, and ‡Department of Medicine, Center for Healthcare Improvement and Patient Safety, University of Pennsylvania, Philadelphia, Pennsylvania.


Mild or moderate sedation for procedures frequently is administered outside the operating room by resident physicians with varying degrees of training. An adverse event at our institution involving procedural sedation prompted us to conduct a survey among resident physicians. This survey investigated resident knowledge and attitudes about sedatives and analgesics, in addition to knowledge of risk factors for sedation-related adverse events. The survey identified a range of knowledge deficiencies among resident physicians and a lack of awareness of institutional sedation policies. Identification of knowledge gaps facilitated an educational initiative that promoted training in the pharmacology of sedatives and analgesics, safe sedation practices, and institutional sedation policies. Additional interventions included updating our sedation policy and creation of an electronic order set to facilitate the safe prescription of sedatives.

[Indexed for MEDLINE]

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