A Method for Measuring System Safety and Latent Errors Associated with Pediatric Procedural Sedation


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Abstract

The practice of sedating patients in the hospital for diagnostic and therapeutic procedures may be associated with life-threatening respiratory depression. We describe a method that uses a simulated event to identify latent system failures. A simulated scenario was developed that was reproducible with realistic physiology that degraded over time if no interventions occurred and improved when treated appropriately. Management of the scenario was observed in an ideal setting, a radiology department, and an emergency department. Event management was videotaped. The simulator’s physiological data were saved automatically at 5-s intervals. Deviations from “best practice” were measured by using a set of video markers for event detection, diagnosis, and treatment. The simulator data files were used to calculate time out of range for critical variables. Hypoxia and hypotension lasted 4.5 and 5.5 min in the radiology and emergency departments, respectively, compared with 0 min in the gold standard setting. Many latent failures were identified by reviewing the video. This study supports the feasibility of using available human simulation as a crash-test dummy to more objectively quantify rescue system performance in actual sedation care settings. This method revealed vulnerabilities in personnel and in care systems even though sedation care regulatory requirements were met.

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