Quality and Safety Corner
Safety Checklists in Procedural Sedation
By Cheri Landers, MD, FAAP, FCCM
Since the publication of the Checklist Manifesto (1) and the introduction of the World Health Organization’s surgical checklist in 2009 (2), checklist usage in healthcare and publications on their use have become increasingly popular.
The argument for the use of checklists, as is so often when approaching safety in healthcare, comes from use in the airline industry. As reviewed in the October 2015 article in Anesthesia and Analgesia by Jens Krombach, et al (3), airline pilots go through a multitude of checklists prior to, during and after a flight. These checklists often cover items that most, if not all, pilots would remember to check with every flight. Yet, the checklists are mandatory, emphasized during pilot training and embedded in their culture.
The reason is that even though the checklists cover tasks that are routine, the distracted or fatigued pilot or the flight that becomes something other than routine are the situations where the checklist becomes the most valuable. However, only with regular, routine, daily, every flight usage, does the checklist achieve its safety goal. What human being realizes and admits they are distracted or fatigued and reaches for a checklist for help?
Are there roles for checklists in pediatric procedural sedation? Probably. What items a specific sedation checklist includes will likely depend on the center and service providing sedation. Using the Krombach article as a template, opportunities exist for checklists at room setup, pre-induction, post-induction, intermittently during a prolonged sedation and even following the procedure. The Kentucky Children’s Hospital (KCH) Sedation Service has used some form of a checklist at room setup and pre-induction for several years.
Over time, the individual items on the KCH checklist have changed as we have discovered what is most useful (and most used). A useful checklist has certain characteristics as described by Kromberg, most of which our team has come to agree with as well.
A useful checklist:
- is short – no longer than 10 items per checklist
- is succinct – each item should have the fewest words possible to describe the task
- covers important safety tasks that if overlooked could result in patient safety issues. Reminders to document are not the goals of the safety checklist.
Examples of possible items to include on a room setup checklist are suction setup and function check, bag-mask connected to oxygen and checked, and emergency airways available and sizes confirmed. Pre-induction checklists might include current patient weight, pre-induction vitals and assessment, confirmation of induction medication dosage, patient allergy review, or review of specific patient related sedation concerns. Intra-procedural checklists like those described by Kromberg for anesthesia cases are not likely to be needed frequently due to the nature of procedural sedation.
However, post-induction or intra-procedural sedation checklists might include eye protection, patient positioning, review of medication infusion rates/doses, and every 30 minutes eye and positioning check. A post procedure checklist could cover opportunities noticed during the procedural sedation such as equipment or staffing concerns.
There is a second situation where checklists or cognitive aids can be valuable. In the airline industry this other group of checklists is used in rare or emergency situations and allow the pilots to systematically work through an alarm or emergency situation and problem solve in a logical manner without depending on his or her memory in a stressful situation. These types of checklists are less common in healthcare, but are not non-existent.
One app, PediCrisis (Pediatric Critical Events Checklist) from Children’s Hospital of Philadelphia(4), is available for smart phones and provides symptom lists and treatment checklists for multiple anesthetic emergency scenarios right at your fingertips.
Take a moment to read the short piece by Jens Kromberg and his colleagues in the October 2015 issue of Anesthesia and Analgesia(3) reviewing airline checklists and Kromberg’s project to introduce checklists throughout the surgical anesthesia process at San Francisco General Hospital. Perhaps your sedation team will be inspired to adopt a checklist (or two) for patient safety.
Gawande, A. (2009) The Checklist Manifesto: How to Get Things Right. New York, NY: Metropolitan Books, Henry Holt and Co.
Haynes AB,Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–499.
Krombach JW, Marks JD, Dubowitz G, Radke OC. Development and Implementation of Checklists for Routine Anesthesia Care: A Proposal for Improving Patient Safety. Anesth Analg. 2015 Oct;121(4):1097-103.
- Pediatric Critical Events Checklist. (2013). The Children’s Hospital of Philadelphia (Version 1.0) [Mobile application software]. Retrieved from http://itunes.apple.com
The Repository of Guidelines
By Urmila Tirodker, MD and Cheri Landers, MD
The SPS Quality and Safety Committee is committed to providing safe, high quality pediatric procedural sedation care globally. We have attempted to provide SPS members with a rapid online resource of a repository of sedation guidelines that span various disciplines and countries. This section is a review and repository of several such landmark and most cited sedation guidelines put forth by professional societies and peer reviewed articles that pertain to areas of clinical practice, administrative practice, regulatory standards, quality and safety in pediatric sedation across various disciplines.
The Repository of Guidelines is an evolving group of documents. If you know of a more recent guideline, have a new article, or a published protocol that you feel should be considered for inclusion in the repository, please let us know. Send us your suggestion at email@example.com.