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Procedural sedation in the emergency department


Are safety guidelines being followed when administering procedural sedation in the emergency department? Between November 2004 and November 2008, the NPSA received 498 alerts of patients being given the wrong dose of midazolam for procedural sedation [1]. In the first 5 years of midazolam use there were 86 deaths, most related to procedural sedation [2].


We searched through the controlled drugs book in resuscitation over a 2-month period and found a list of patients who had received midazolam or fentanyl. From this, we could make a search for the relevant A and E notes for these patients. From these notes, we looked for (see shorthand in Table 1): verbal consent documentation (consent), past medical history recorded (pmhx), safe initial dose of midazolam (midaz), pre-procedure monitoring (pre), post-procedure monitoring (post), and monitoring for 1 hour before discharge (1 hr). Following introduction of a reminder in the controlled drugs book/sedation room and staff education, the case notes were analysed over another 2-month period (24 sets of notes) to assess practise against safety guidelines.


See Table 1 (key for shorthand in Methods).


The re-audit notices within the procedural sedation room and controlled drug book front cover served as a reminder of good practise. The visibility of this reminder (within the CD book) helped ensure better adherence to the audit standard. This reminder will now be kept within the CD book.

Table 1 Before and after education programme and reminder in the controlled drugs book


  1. 1.


  2. 2.

    Epstein B: Data Retrieval Unit HFD-737. Department of Health and Human Services, Office of Epidemiology and Biostatistics, Center for Drug Evaluation and Research; 27 June 1989

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Correspondence to MS Shah.

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Shah, M., Shah, F., Pope, K. et al. Procedural sedation in the emergency department. Crit Care 17, P380 (2013).

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  • Emergency Department
  • Fentanyl
  • Midazolam
  • Initial Dose
  • Good Adherence