We are all responsible for practicing safety behaviors for error prevention, especially in the sedation environment. As key members of the sedation team, nurses are often the first to identify “safe catches” in the sedation environment. Here are a few examples:
- While performing a presedation assessment, the nurse practitioner notices the inpatient’s clear liquid tray at his bedside. The Gatorade appeared cloudy, and when “practicing with a questioning attitude”, she identified that the liquid contained a powdered starch, rendering it cloudy, and thus qualified it as a “solid”. The sedated MRI had to be rescheduled for a later time slot that day. This case in turn was then escalated to the food services department and increased the staff awareness that some Gatorade solutions may contain protein or starch powder.
- A five year old arrives for a sedated MRI. His lips and tongue are bright red and his breath smells like cherries. Both he and his mother deny that he has had anything but a few sips of water early that morning, but by practicing with a questioning attitude, the nurse finds out that he ate a red gummy bear that he found in the seat of the car.
- During the sedation recovery phase, the bedside nurse noticed that the parent had left the bedside and the child was at risk of falling since the side rail was down.
- What about the child that is cared for by several staff members during sedation and recovery as the needs of the unit change, lunch breaks happen, and perhaps the recovery extends across shifts? Written or online handoff tools are essential to ensure thorough communication among the staff who care for that patient throughout all phases of sedation until discharge or transfer back to the inpatient unit.
- We have all dealt with the patient experiencing emergence from sedation, and are responsible for instituting measures to keep the thrashing/screaming child safe from harm to himself and others.
I could go on and on with stories. We have all gone through training, whether it be mandatory online education, live programs or daily safety huddles in which we are reminded to pay attention to detail and be mindful of what we are doing at all times. We perform self checks using STAR (stop-think-act-review) and we use ISBAR-Q (identification-situation-background-assessment-recommendation-questions) to communicate information clearly. We conduct a “time out” before sedation encounters so that we are communicating with fellow team members. And during all of this, we are supporting each other and maintaining accountability, not just for our own actions, but for our teammates’ actions as well.
Let’s not take any of these safety measures for granted. They are not just a bunch of acronyms to memorize and perhaps even have printed on a card that is clipped to an ID badge, but instead should represent safety behaviors that we believe in, become ingrained in our practice and safety tools that we use every day in our practice to prevent errors from happening.
As members of the Society for Pediatric Sedation, we all strive to promote safe care. It starts with the nurses on the phones triaging patients and continues with the nurses caring for them at the bedside. We would like for you to share your safety stories with us. We can all learn from each other. Consider becoming a member of the Nursing and Allied Health Committee and attending the annual conference to meet and share your experiences with fellow nurses from around the globe. I look forward to meeting you in Atlanta!
Lorie Reilly
Sedation NP at The Children’s Hospital of Philadelphia
reillyl@email.chop.edu
