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Improving the Safety of Pediatric Sedation: Human Error, Technology, and Clinical Microsystems

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Pediatric Sedation Outside of the Operating Room

Abstract

Recent years have seen significant improvements in the safety of a number of areas of health care. However, evidence would suggest that the practice of pediatric sedation outside of the operating room is an area where unaddressed complexities and risks in care remain. In addition, the number of children receiving sedation outside of the operating room is on the increase, emphasizing the need to realize opportunities to improve safety. We outline the risks inherent in sedating children in the context of both the human factors and system factors perspectives. We incorporate examples from other high-technology industries such as aviation and nuclear power generation to allow a better understanding of why things go wrong during sedation. The value of prior risk assessment, communication, checklists, and formalized recovery pathways are discussed, and new directions for the development of safety initiatives are identified. Finally a number of practical steps based on existing successful safety approaches are given, with an emphasis on the demonstration of efficacy and the sharing of successful safety solutions.

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Notes

  1. 1.

    Some of the material in the section Error Types is drawn from the first author’s PhD thesis: Webster CS. Implementation and Assessment of a New Integrated Drug Administration System (IDAS) as an Example of a Safety Intervention in a Complex Socio-technological Workplace. Auckland: University of Auckland, 2004.

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Acknowledgements

We would like to thank Dr. Karen Domino, Dr. Karen Posner, and the American Society of Anesthesiologists Closed Claims Project for supplying the data in Table 30.4.

Authors Craig S. Webster, Michael Stabile, and Alan F. Merry own shares in Safer Sleep Limited, a company that aims to improve safety in medicine and which manufactures the new system mentioned in references [18] and [174]. Alan F. Merry founded and is a Director of Safer Sleep Limited.

Alan F. Merry chairs the Board of the Health Quality and Safety Commission in New Zealand. He is Head of the School of Medicine in Auckland, which includes the Simulation Centre for Patient Safety (in which some of the research referenced in this chapter was conducted). He was the anesthesia lead for the development of the WHO Surgical Safety Checklist.

The remaining author has no competing interests to declare.

Author information

Authors and Affiliations

  1. Centre for Medical and Health Sciences Education, University of Auckland, Private Bag 92-019, Auckland, 1142, New Zealand

    Craig S. Webster B.Sc., M.Sc., Ph.D.

  2. Department of Anaesthesiology, University of Auckland School of Medicine, Auckland, New Zealand

    Brian J. Anderson Ph.D., F.A.N.Z.C.A., F.J.F.I.C.M.

  3. Department of Anesthesia, Centennial Medical Center, Nashville, TN, USA

    Michael J. Stabile M.D., M.B.A.

  4. St. Louis University School of Medicine, St. Louis, MO, USA

    Michael J. Stabile M.D., M.B.A.

  5. Department of Anaesthesiology, University of Auckland and Auckland City Hospital, Auckland, New Zealand

    Alan F. Merry F.A.N.Z.C.A, F.P.M.A.N.Z.C.A.

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  1. Craig S. Webster B.Sc., M.Sc., Ph.D.
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Correspondence to Craig S. Webster B.Sc., M.Sc., Ph.D. .

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  1. Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts, USA

    Keira P. Mason

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Webster, C.S., Anderson, B.J., Stabile, M.J., Merry, A.F. (2015). Improving the Safety of Pediatric Sedation: Human Error, Technology, and Clinical Microsystems. In: Mason, K. (eds) Pediatric Sedation Outside of the Operating Room. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1390-9_30

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