185 / 242
185
NATIONAL AUDIT INTO THE SAFETY OF DEEP SEDATION
14
Several surgical studies have introduced the concept of failure to rescue.
10,11
Failure
to rescue means that mortality rates between hospitals often not differ because of
different complication rates but because of the ability to effectively rescue patients from
complications.
10,11
This concept is also applicable to PSA and underlines the importance of
on-going performance improvement programs in order to ensure good patient outcome.
A national complication registry of sedation practice should be set up to serve as a source
for on-going quality improvement.
The limitation of this study is that most data was self-reported by the SP. This could have
led to the underreporting of sedation related AEs. A fully automated AE reporting system
from the electronic anaesthetic case notes could prevent underreporting and could be
established for future registrations.
CONCLUSIONS
This is the first national audit into the safety of moderate to deep sedation performed
by sedation practitioners in the Netherlands. This study found low rates of sentinel and
moderate risk AEs and demonstrated that SPs are able to effectivelymanage sedation related
events
.
On-going evaluation of care processes is required to ensure further performance
improvement.