Research Activities, May 2010: Patient Safety and Quality: Adverse events occurring during pediatric sedation are recorded in charts but not always reported

Patient Safety and Quality
Adverse events occurring during pediatric sedation are recorded in charts but not always reported

Although most adverse events that occur while children are sedated are considered minor, they are not reported as often as they should be, according to a new study from researchers at Children's Hospital Boston. The team examined 5,045 patient sedation records and found that 329 adverse events occurred, for a rate of 6.52 percent. Of those adverse events, 232 were considered minor, such as the patient vomiting or waking before the procedure was completed; while 97 were deemed serious, such as the need for resuscitation, cardiovascular complications, or paradoxical reaction to the anesthesia (e.g., rage).

Although minor events were more common and more likely to be documented in the patients' file, they were not as likely as serious events to be reported by the perianesthesia nurse. For example, a patient waking before the procedure was completed, considered a minor event, was noted in the records of nearly 120 patients but reported in just over 20 cases. Nurses may underreport minor sedation incidents because they perceive them as unpreventable, despite the excellent care provided, note the researchers.

Their findings suggest that the use of voluntary incident reports may lead to an underestimate of the actual number of adverse events that occur during pediatric sedation. While some perianesthesia nurses may avoid reporting adverse events as a way to preempt possible litigation, not having this information impedes improvements in care quality. This study was funded in part by the Agency for Healthcare Research and Quality (HS11416).

See "Nurse reports of adverse events during sedation procedures at a pediatric hospital," by Jenifer R. Lightdale, M.D., M.P.H., Lisa B. Mahoney, B.S., Meghan E. Fredette, B.S., and others in the October 2009 Journal of PeriAnesthesia Nursing 24(5), pp. 300-306.

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Research Activities, May 2010: Patient Safety and Quality: Adverse events occurring during pediatric sedation are recorded in charts but not always reported