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From Root Cause to Action Plan

How an Adverse Event Uncovered Deficiencies in Resident Knowledge of Sedation Policies and Practices

Pieczynski, Lauren M. MD; Raiten, Jesse M. MD; Lane-Fall, Meghan B. MD, MSHP

doi: 10.1213/XAA.0000000000000249
Case Reports: Education

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.

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.

Accepted for publication June 26, 2015.

Funding: This work was unfunded. Dr. Lane-Fall receives research and salary support from the Anesthesia Patient Safety Foundation and the University of Pennsylvania.

The authors declare no conflicts of interest.

Address correspondence to Lauren M. Pieczynski, MD, Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Dripps Library-5 Dulles, Philadelphia, PA 19104. Address e-mail to

Mild or moderate sedation is administered commonly to patients undergoing minor procedures outside the operating room. Sedation often is provided by nonanesthesia providers from a wide range of medical backgrounds.1 In many teaching hospitals, sedation may be administered by physicians in training (residents), including residents from specialties other than anesthesiology. This model of staffing for minor procedures is practiced frequently for bedside procedures that require IV sedatives (e.g., joint reductions, cardioversions, transesophageal echocardiograms, endoscopy).2 In the United States in general, physician credentialing limits the scope of practice to procedures that physicians can perform safely. Resident physicians are not credentialed for specific procedures, but have a scope of practice determined by their supervising physician. Although this arrangement may maximize the learning potential for residents, it may introduce variability in knowledge of skills.

The recent introduction by the Accreditation Council for Graduate Medical Education (ACGME) of Resident Milestones is a framework for assessment of an individual’s knowledge, skills, and performance as he or she progresses through residency. Progression through the milestones represents graduation targets, but is not a requirement for graduation. A resident’s readiness for graduation is ultimately the decision of the residency program director. A resident’s ability to perform mild-to-moderate sedation is not specifically mentioned as a competency goal in most specialty-specific milestones.

Root cause analysis of an adverse event at our hospital during moderate sedation for a minor procedure identified a lack of resident knowledge of sedation practices as contributing to the poor outcome. The root cause was identified as the lack of a preexisting formal curriculum and evaluation method for assessing residents’ competency in safe administration of sedation.

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This study was submitted to the IRB at the University of Pennsylvania and was exempted from review because it was conducted for the purpose of quality improvement. After review of the final manuscript, approval for publication of this study was granted by the IRB. We conducted a survey of resident physicians to assess their knowledge of medications and techniques used for sedation, their awareness of safety culture surrounding sedation practices at one teaching hospital in our health system, and their educational style preferences. The survey results were used to facilitate development of a targeted curriculum to address gaps in knowledge about safe sedation practices.

A pilot survey of residents in the surgical intensive care unit was conducted to assess readability and question clarity. The final survey (Appendix 1) was administered to residents in anesthesiology, emergency medicine, internal medicine, obstetrics-gynecology, radiology, and surgery. Permission to administer the survey was obtained from appropriate residency program directors. The survey was Internet-based and administered via REDCap, the Research Electronic Database Capture program first developed at Vanderbilt University. Participants were asked explicitly not to study for the questionnaire because we wanted to assess baseline knowledge.

We used descriptive statistics to characterize participant demographics and responses to survey questions. For comparisons between anesthesiology residents and nonanesthesiology residents, we used χ2 testing for categorical variables and t tests for continuous variables. All statistical testing was performed with Stata SE (version 13.1; StataCorp LLC, College Station, TX). A P value of 0.01 was used as the cutoff for statistical significance, given multiple comparisons in survey categories.

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Characteristics of Survey Respondents

Table 1

Table 1

Two hundred eighteen resident and fellow-level physicians completed the survey. The majority of respondents were residents or fellows in surgery (60), internal medicine (53), and anesthesiology (43). The overall response rate ranged from 33% (internal medicine) to 53% (emergency medicine). Eighty-two percent of respondents were between postgraduate years 1 and 4. Ten percent of the respondents were fellows (Table 1).

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Knowledge Evaluation Questions

The majority (64%) of respondents correctly identified dosing equivalences for morphine and hydromorphone (range 50%–75%). A similar percentage (61%, range 42%–72%) correctly identified flumazenil dosing for benzodiazepine reversal. Only 46% (range 14%–72%) knew the starting dose of naloxone for opioid reversal. The majority (71%–83%) of respondents correctly identified medications, such as benzodiazepines, that are commonly avoided in elderly patients. Seventy-four percent (range 50%–100%) of those surveyed identified a short mentohyoid distance as a risk factor for a difficult airway. Many of the known risk factors for obstructive sleep apnea, which may affect the choice of sedative during conscious sedation, were identified correctly. The notable exceptions were age >50 years and hypertension. The only statistically significant difference in knowledge between anesthesiology residents and residents in other specialties was the starting dose of naloxone for opioid reversal in a spontaneously breathing patient. Twenty-four of 33 (72.7%) anesthesiology residents chose the correct dose of 40 μg compared with 58 of 145 (40%) nonanesthesiology residents (P = 0.001).

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Experience and Attitude Toward Sedative and Analgesic Practices

Only 8% (range 2%–21%) of respondents were aware that there was a minimal and moderate sedation policy within our hospital. The mean level of satisfaction with sedative and analgesic education was 54/100 (range 35–75), although respondents’ level of confidence in knowledge of opioids and benzodiazepines was slightly greater (62–64/100, range 41–70). Respondants were considerably more confident prescribing analgesics to opioid-naive patients (mean level of confidence 74/100, range 49–83) compared with opioid-tolerant patients (mean level of confidence 64/100, range 45–76). Anesthesiology residents reported greater confidence than nonanesthesiology residents in all categories queried, but the only statistically significant difference was confidence in benzodiazepine dosing (mean 70.9 ± 17.8 for anesthesiology residents versus 59.9 ± 18.9 for nonanesthesiology residents; P = 0.003).

Table 2

Table 2

When given a choice of 5 educational strategies to improve knowledge about sedative and hypnotic techniques, didactic lectures were significantly more popular than other interventions, and were identified as the favored technique by 60% of respondents (Table 2).

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The wide range in knowledge among residents and fellows at our hospital regarding mild and moderate sedation may represent an area for improvement at other academic institutions nationwide. Our findings are consistent with previous surveys of resident knowledge of sedation practices and highlight the need for educational initiatives.3,4 Currently, in the ACGME milestone framework, a resident’s ability to perform mild-to-moderate sedation is not included in each specialty’s milestones. Emergency medicine and radiology milestones mention sedation as a milestone, while surgery, obstetrics-gynecology, and internal medicine milestones do not.1,a

Identification of deficiencies in knowledge about sedative medications and lack of awareness of related policies permitted important changes in the administration of mild and moderate procedural sedation at our hospital. Before our intervention, there was no standard curriculum or expected demonstration of competency prior to residents’ ordering of sedative medications. There were no changes in resident scope of practice after the intervention because residents are not credentialed by skill set, but rather provide care under an attending physician’s supervision.

We updated our policy for the administration of sedation for diagnostic and therapeutic interventions. The updated policy was distributed to program directors, resident physicians, and nursing staff. Drawing on guidelines developed by the American Society of Anesthesiologists, the new curriculum reviewed key physiology and pharmacology related to sedation.5 The policy defined goals of sedation, authorized providers, and defined the role of nursing staff. With this new policy, authorization to provide mild-to-moderate sedation is given by the department chair of each residency subspecialty. Residents must complete an online moderate sedation knowledge competency assessment. In addition, trainees must either go through a sedation simulation or participate in 5 procedures involving moderate sedation with direct supervision by a credentialed faculty member.

Educational sessions were directed toward resident physicians. Didactic sessions were the favored educational style preference among residents and included a multidisciplinary grand rounds discussion, as well as smaller group discussions within specialties. Finally, we created a standardized order within the electronic medical record to guide selection and dosing of sedative and analgesic medications. This was created to facilitate appropriate sedation practice in an out-of-operating room environment.

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a ACGME Milestones. Available at: Accessed May 13, 2015.
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