title: Utility of Procedural Sedation as a Marker for Quality Assurance in Emergency Medicine.
abstract: BACKGROUND
  The Joint Commission requires health care organizations to monitor and evaluate procedural sedation. However, the utility of mandatory review of procedural sedation in evaluating health care quality is unknown.
  
  
  OBJECTIVE
  To determine whether procedural sedation is a useful marker for evaluating error in the emergency department (ED).
  
  
  METHODS
  We prospectively collected data for patients presenting to an urban, tertiary care, academic medical center ED between October 2013 and June 2015. We used an automated, electronic tracking system to identify patients who underwent procedural sedation. We randomly assigned cases to physician reviewers. Reviewers used a structured tool to determine the presence of error and adverse events. If a reviewer felt that the case had an error or adverse event, it was referred to a quality assurance (QA) committee, which made a final determination as to whether or not an error or adverse event occurred.
  
  
  RESULTS
  There were 166 cases of procedural sedation reviewed. Two errors were identified, for an error rate of 1.2% (95% confidence interval [CI] 0.003-0.043). Both errors occurred during the use of propofol to facilitate upper gastrointestinal endoscopy. Neither error resulted in an adverse event. One adverse event was identified that was unrelated to physician error (0.6%; 95% CI 0.001-0.033).
  
  
  CONCLUSIONS
  Routine review of procedural sedation performed in the ED offers little advantage over existing QA markers. Directed review of high-risk cases, such as those involving endoscopy or other longer-duration procedures, may be more useful. Future studies focusing quality review on projected high-risk sedation cases may establish more valuable markers for QA review.
authors.affiliation: Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Foley
authors.affiliation: Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Richard E
authors.initials: RE
authors.lastname: Wolfe
authors.affiliation: Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Burstein
authors.affiliation: Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Edlow
authors.affiliation: Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Shamai A
authors.initials: SA
authors.lastname: Grossman
mesh_terms: D015331:Cohort Studies; D016292:Procedural Sedation / Q000009:adverse effects* / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000706:statistics & numerical data; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects; D005045:Etomidate / Q000009:adverse effects / Q000627:therapeutic use; D005283:Fentanyl / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D006993:Hypnotics and Sedatives / Q000009:adverse effects* / Q000627:therapeutic use; D007649:Ketamine / Q000009:adverse effects / Q000627:therapeutic use; D019300:Medical Errors / Q000706:statistics & numerical data; D008874:Midazolam / Q000009:adverse effects / Q000627:therapeutic use; D000067491:Near Miss, Healthcare / Q000639:trends; D015742:Propofol / Q000009:adverse effects / Q000627:therapeutic use; D011446:Prospective Studies; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data*
chemical_list: D006993:Hypnotics and Sedatives; D007649:Ketamine; D008874:Midazolam; D005283:Fentanyl; D015742:Propofol; D005045:Etomidate
keywords: adverse event; conscious sedation; error; procedural sedation; quality assurance