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Over sedation for emergency procedures in isolated locations | Signal

Reference number
Issue date14 February 2011

This Signal concerns the risk to patients from sedation given for emergency procedures in isolated locations, often out of hours by junior doctors. A sample report reads:

“A 93yo man admitted with acute confusion…During the night he … was sedated twice with lorazepam … CT was requested. He was sent to the scanner [at 0530] but was too agitated to scan. Two FY1 doctors gave two further doses of lorazepam in the imaging suite. About an hour later he … was sent back to the ward where he … later died.”

A search of the National Reporting and Learning System (NRLS) found 4618 incidents related to sedation in non-critical care areas (of incidents reported 1 November 2003 to 4 October 2010). A quarter of these were for procedures on emergency patients in isolated locations. This included 34 death or severe harm incidents (one third of all the death and severe incidents in this search).

In addition, many incidents involved:

• patients with co-morbid diseases;
• a range of staff types;
• the lack of availability of anaesthesia/ITU staff or the failure to ask for them.

Harm occurred either when sedation was indicated but too much was given, or sedation was given instead of diagnosing the cause of the symptoms that triggered sedation.

Over sedation occurred because of:

• a failure to titrate to the individual;
• wrong doses because of errors in dilutions;
• failure of communication about the contents of syringes (see Promoting safer use of injectable medicines);
• combinations of sedative drugs.

Diagnostic errors were caused by:

• not considering that agitation may be a symptom of another disease;
• false reassurance that impairment of consciousness is because of a previously given sedative drug.

NHS organisations should consider reviewing their policies on sedation to ensure these include appropriate advice for emergency situations (and not just the circumstances of a consultant delivering sedation for elective procedures). It is important that guidance covers sedation for emergency patients and addresses the situation of junior doctors being supervised remotely. It may not be possible to reliably produce ‘conscious sedation’ in emergency patients.

For more information see guidelines on Safe Sedation Practice.


We would like to hear from you – please contact us with your initiatives to reduce risks in any of these areas.

Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.