Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist.

Simona Librov; Itai Shavit

Study

Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist.

September 2, 2020

Librov S, Shavit I. J Pain Res. 2020;13:1797-1802.

View more articles from the same authors.

This retrospective study evaluated the impact of a pre-sedation checklist on serious adverse events among children treated with ketamine and propofol in a pediatric emergency department. There were significantly more serious adverse events recorded after the implementation of the checklist.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Cold debriefings after in-hospital cardiac arrest in an international pediatric resuscitation quality improvement collaborative.

September 2, 2020

Improving patient handoffs and transitions through adaptation and implementation of I-PASS across multiple handoff settings.

September 16, 2020

Implementation of a parent-centered approach to the preinduction checklist in pediatric surgery.

February 3, 2021

Safety in pediatric hospice and palliative care: a qualitative study.

September 23, 2020

Five-year audit of adherence to an anaesthesia pre-induction checklist.

March 30, 2022

A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist.

February 2, 2022

Persisting high rates of omissions during anesthesia induction are decreased by utilization of a pre- & post-induction checklist.

February 1, 2023

Adverse events and their contributors among older adults during skilled nursing stays for rehabilitation: a scoping review.

December 8, 2021

Association of current opioid use with serious adverse events among older adult survivors of breast cancer.

October 14, 2020

Cognitive bias impact on management of postoperative complications, medical error, and standard of care.

November 4, 2020

The surgical ward round checklist: improving patient safety and clinical documentation.

November 20, 2019

The effects of hospital-physician financial integration on adverse incident rate: an agency theory perspective.

October 21, 2020

Improving safety recommendations before implementation: a simulation-based event analysis to optimize interventions designed to prevent recurrence of adverse events.

July 7, 2021

Design and implementation of an analgesia, sedation, and paralysis order set to enhance compliance of pro re nata medication orders with Joint Commission medication management standards in a pediatric ICU.

December 9, 2020

A blueprint for success: implementation of the Center for Medicare and Medicaid Services mandated anesthesiology oversight for procedural sedation in a large health system.

June 15, 2022

Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study.

October 7, 2020

Time out! Rethinking surgical safety: more than just a checklist.

April 28, 2021

A systems approach to address the impact of second victim phenomenon.

December 9, 2020

September 15, 2021

Adverse drug event-related admissions to a pediatric emergency unit.

April 14, 2021

A systems approach to analyzing and preventing hospital adverse events.

June 24, 2020

Adverse events in intensive care and continuing care units during bed-bath procedures: the prospective observational NURSIng during critical carE (NURSIE) study.

December 23, 2020

Reduction in omission events after implementing a rapid response system: a mortality review in a department of gastrointestinal surgery.

March 15, 2023

Why an open disclosure procedure is and is not followed after an avoidable adverse event.

September 8, 2021

A randomized trial of a multifactorial strategy to prevent serious fall injuries.

July 29, 2020

How does the WHO Surgical Safety Checklist fit with existing perioperative risk management strategies? An ethnographic study across surgical specialties.

March 18, 2020

The implementation of communication didactics for OB/GYN residents on the disclosure of adverse perioperative events.

July 7, 2021

Impact of remote consultations on antibiotic prescribing in primary healthcare: systematic review.

December 2, 2020

Predictors of serious opioid-related adverse drug events in hospitalized patients.

July 8, 2020

The second victim of unanticipated adverse events.

December 14, 2022

Pediatric transport safety collaborative: adverse events with parental presence during pediatric critical care transport.

November 10, 2021

Association between language use and ICU transfer and serious adverse events in hospitalized pediatric patients who experience rapid response activation.

August 17, 2022

Supporting recovery after adverse events: an essential component of surgeon well-being.

February 10, 2021

Engaging patients and informal caregivers to improve safety and facilitate person- and family-centered care during transitions from hospital to home: a qualitative descriptive study.

July 10, 2019

Exploring psychological safety in healthcare teams to inform the development of interventions: combining observational, survey and interview data.

October 28, 2020

Effect of medication reconciliation on patient reported potential adverse events after hospital discharge.

September 8, 2021

Association between parent comfort with English and adverse events among hospitalized children.

November 11, 2020

Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study.

May 11, 2022

2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents from the nation’s largest event reporting database.

May 19, 2021

The role of bias in clinical decision-making of people with serious mental illness and medical co-morbidities: a scoping review.

February 22, 2023

Identifying no-harm incidents in home healthcare: a cohort study using trigger tool methodology.

August 5, 2020

The association of nursing home characteristics and quality with adverse events after a hospitalization.

April 28, 2021

A recent two-fold increase in medical adverse event deaths among US inpatients.

December 21, 2022

Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives.

November 25, 2020

Gender biases in estimation of others' pain.

April 28, 2021

The psychological experience of obstetric patients and health care workers after implementation of universal SARS-CoV-2 testing.

September 2, 2020

What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization.

October 21, 2020

Body mass index category and adverse events in hospitalized children.

July 27, 2022

Interventions and measurements of highly reliable/resilient organization implementations: a literature review.

October 28, 2020

Enhancing patient safety during pediatric sedation: the impact of simulation-based training of nonanesthesiologists.

August 15, 2007

A review of adverse event reports from emergency departments in the Veterans Health Administration.

March 18, 2020

Assessing adverse events after chiropractic care at a chiropractic teaching clinic: an active-surveillance pilot study.

November 4, 2020

Characteristics and unexpected COVID-19 diagnoses in resuscitation room patients during the COVID-19 outbreak - a retrospective case series.

September 30, 2020

Patient outcomes after opioid dose reduction among patients with chronic opioid therapy.

January 12, 2022

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

March 25, 2020

Real-time debriefing after critical events: exploring the gap between principle and reality.

November 18, 2020

Adverse events related to accidental unintentional ingestions from cough and cold medications in children.

August 26, 2020

Predicting avoidable hospital events in Maryland.

December 1, 2021

Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia.

August 10, 2022

Association of opioid consumption profiles after hospitalization with risk of adverse health care events.

June 2, 2021

Development and implementation of a suicide prevention checklist to create a safe environment.

March 4, 2020

Key potentially inappropriate drugs in pediatrics: the KIDs list.

June 24, 2020

Adverse events in women giving birth in a labor ward: a retrospective record review study.

November 3, 2021

A quality improvement initiative using peer audit and feedback to improve compliance with the surgical safety checklist.

July 27, 2022

Comparison of adverse events during procedural sedation between specially trained pediatric residents and pediatric emergency physicians in Israel.

July 30, 2008

Safety climate associated with adverse events in nursing homes: a national VA study.

August 26, 2020

Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments.

October 26, 2022

Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project.

December 22, 2021

Inpatient telemedicine and new models of care during COVID-19: hospital design strategies to enhance patient and staff safety.

September 15, 2021

Impact of pharmacist-led multidisciplinary medication review on the safety and medication cost of the elderly people living in a nursing home: a before-after study.

February 12, 2020

Nurse-reported bullying and documented adverse patient events: an exploratory study in a US Hospital.

June 24, 2020

Bracing for the storm: one health care system's planning for the COVID-19 surge.

November 11, 2020

Register-based research of adverse events revealing incomplete records threatening patient safety.

August 19, 2020

An initiative to reduce insulin-related adverse drug events in a children's hospital.

February 16, 2022

Patient race and opioid misuse history influence provider risk perceptions for future opioid-related problems.

November 4, 2020

An analysis of prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference.

March 1, 2023

Reducing nosocomial transmission of COVID-19: implementation of a COVID-19 triage system.

October 28, 2020

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses.

November 25, 2020

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

September 2, 2020

Understanding how the design and implementation of online consultations affect primary care quality: systematic review of evidence with recommendations for designers, providers, and researchers.

November 30, 2022

Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19.

October 21, 2020

Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database.

July 6, 2022

How satisfied are patients and surgeons with telemedicine in orthopaedic care during the COVID-19 pandemic? A systematic review and meta-analysis.

February 10, 2021

Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus.

March 25, 2020

When safety event reporting is seen as punitive: "I've been PSN-ed!"

September 9, 2020

What is needed to sustain improvements in hospital practices post-COVID-19? A qualitative study of interprofessional dissonance in hospital infection prevention and control.

May 4, 2022

Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds.

October 27, 2021

SAFER Care: improving caregiver comprehension of discharge instructions.

March 31, 2021

Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?

August 25, 2021

Communication with patients and families regarding health care-associated exposure to coronavirus 2019: a checklist to facilitate disclosure.

August 12, 2020

eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.

June 16, 2021

Assessment of nursing home reporting of major injury falls for quality measurement on Nursing Home Compare.

February 5, 2020

Call to action: addressing pediatric fall safety in ambulatory environments.

December 1, 2021

Coping and recovery in surgical residents after adverse events: the second victim phenomenon.

April 20, 2022

Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening.

June 15, 2022

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

A narrative review of strategies to increase patient safety event reporting by residents.

September 30, 2020

Key use cases for artificial intelligence to reduce the frequency of adverse drug events: a scoping review.

March 9, 2022

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Accuracy of practitioner estimates of probability of diagnosis before and after testing.

May 5, 2021

Related Resources

WebM&M Cases

Delayed Evaluation of Abdominal Pain in an Elderly Patient.

September 27, 2023

WebM&M Cases

Misconnection Leading to Arterial Thrombosis

June 28, 2023

In situ simulation as a quality improvement tool to identify and mitigate latent safety threats for emergency department SARS-CoV-2 airway management: a multi-institutional initiative.

June 28, 2023

The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong answer to the wrong question.

June 28, 2023

Patient safety in emergency departments: a problem for health care systems? An international survey.

June 21, 2023

Implementation of ED I-PASS as a standardized handoff tool in the pediatric emergency department.

May 31, 2023

Use of technology to improve the adherence to surgical safety checklists in the operating room.

May 31, 2023

The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services.

May 3, 2023

WebM&M Cases

The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.

April 26, 2023

Crowding in the Emergency Department: Challenges for the Care of Children.

March 15, 2023

Compliance with and barriers to implementing the surgical safety checklist: a mixed-methods study.

March 8, 2023

Crisis in the Lakeshore Hospital ER.

March 8, 2023

Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.

March 1, 2023

In situ simulation as a tool to longitudinally identify and track latent safety threats in a structured quality improvement initiative for SARS-CoV-2 airway management: a single-center study.

February 22, 2023

Misdiagnosis in the emergency department: time for a system solution.

February 8, 2023

"Do no harm": promoting anti-racist policing in pediatric emergency departments through 20 practice change considerations.

February 1, 2023

Diagnostic Errors in the Emergency Department: A Systematic Review.

December 21, 2022

Implementation and facilitation of post-resuscitation debriefing: a comparative crossover study of two post-resuscitation debriefing frameworks.

November 2, 2022

Improving discharge safety in a pediatric emergency department.

October 26, 2022

Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities.

September 7, 2022

WebM&M Cases

EMS Perils from Hospital Overcrowding

August 31, 2022

WebM&M Cases

Miscommunication During the Interhospital Transport of a Critically Ill Child

August 31, 2022

Emergency department adverse events detected using the emergency department trigger tool.

August 24, 2022

How safe are paediatric emergency departments? A national prospective cohort study.

August 3, 2022

Evaluation of feedback modalities and preferences regarding feedback on decision-making in a pediatric emergency department.

July 6, 2022

Reducing pediatric emergency department prescription errors.

June 22, 2022

Automated dispensing cabinet overrides-an evaluation of necessity in a pediatric emergency department.

May 25, 2022

Use of e-triggers to identify diagnostic errors in the paediatric ED.

April 6, 2022

Medication safety in the emergency department: a study of serious medication errors reported by 101 hospitals from 2011 to 2020.

March 30, 2022

Antibiotic prescribing errors in patients discharged from the pediatric emergency department.

March 30, 2022

See More About The Topic

Emergency Departments

Quality and Safety Professionals

Pediatric Emergency Medicine

Specific to High-Risk Drugs

Opiates/Narcotics

Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site