title: From Root Cause to Action Plan: How an Adverse Event Uncovered Deficiencies in Resident Knowledge of Sedation Policies and Practices.
abstract: 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.
authors.affiliation: 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.
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Pieczynski
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Raiten
authors.forename: Meghan B
authors.initials: MB
authors.lastname: Lane-Fall
mesh_terms: D002983:Clinical Competence / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D016292:Procedural Sedation / Q000009:adverse effects* / Q000379:methods; D004636:Emergency Service, Hospital / Q000331:legislation & jurisprudence*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D010820:Physicians; D011787:Quality of Health Care; D011795:Surveys and Questionnaires