TY - JOUR
T1 - Patient safety incidents during overnight polysomnography
T2 - A five-year observational cohort study
AU - Kolla, Bhanu Prakash
AU - Lam, Erek
AU - Olson, Eric
AU - Morgenthaler, Timothy I.
N1 - Copyright:
Copyright 2013 Elsevier B.V., All rights reserved.
PY - 2013
Y1 - 2013
N2 - Introduction: Attended polysomnography (PSG) is a common procedure and is regarded as relatively safe. There have been few systematic evaluations of adverse events occurring during PSG. An understanding of the frequency and type of the adverse events during PSG should inform risk mitigation plans and the development of guidelines for sleep center accreditation. We aimed to identify, tabulate, and classify all adverse events that occurred during overnight PSG conducted at an accredited sleep center over a five-year period. Methods: All adverse events occurring from Jan 1, 2005, to Dec 31, 2010, at the Center for Sleep Medicine, Mayo Clinic, were identified. Information was collated from calls made to emergency responders, to the adverse event reporting system, and events forwarded to the medical director. Results: A total of 36,141 PSGs were performed over the study duration. Fifty-eight adverse events occurred during the study period (1 event/623 PSGs). Most adverse events were cardiac in nature (17/58; 29.3%), a majority involving acute chest pain. Falls were the next most common (20.6%), followed by neurologic (8.6%), pulmonary (3.4%), and psychiatric (3.4%) events. The rest were classified as miscellaneous. There were no patient deaths during PSGs. The majority of patients experiencing an adverse event were transported to the emergency room (37/58; 63.79%). Of these, 15/37 (40.54%) were admitted to the hospital, and 3 required an ICU bed. Conclusion: Adverse events during a PSG were relatively uncommon. Previous emphasis on cardiac arrhythmias may be overstated, as chest pain and patient falls were commonest and resulted in hospitalization more often.
AB - Introduction: Attended polysomnography (PSG) is a common procedure and is regarded as relatively safe. There have been few systematic evaluations of adverse events occurring during PSG. An understanding of the frequency and type of the adverse events during PSG should inform risk mitigation plans and the development of guidelines for sleep center accreditation. We aimed to identify, tabulate, and classify all adverse events that occurred during overnight PSG conducted at an accredited sleep center over a five-year period. Methods: All adverse events occurring from Jan 1, 2005, to Dec 31, 2010, at the Center for Sleep Medicine, Mayo Clinic, were identified. Information was collated from calls made to emergency responders, to the adverse event reporting system, and events forwarded to the medical director. Results: A total of 36,141 PSGs were performed over the study duration. Fifty-eight adverse events occurred during the study period (1 event/623 PSGs). Most adverse events were cardiac in nature (17/58; 29.3%), a majority involving acute chest pain. Falls were the next most common (20.6%), followed by neurologic (8.6%), pulmonary (3.4%), and psychiatric (3.4%) events. The rest were classified as miscellaneous. There were no patient deaths during PSGs. The majority of patients experiencing an adverse event were transported to the emergency room (37/58; 63.79%). Of these, 15/37 (40.54%) were admitted to the hospital, and 3 required an ICU bed. Conclusion: Adverse events during a PSG were relatively uncommon. Previous emphasis on cardiac arrhythmias may be overstated, as chest pain and patient falls were commonest and resulted in hospitalization more often.
KW - Adverse events
KW - Polysomnography
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U2 - 10.5664/jcsm.3172
DO - 10.5664/jcsm.3172
M3 - Article
C2 - 24235904
AN - SCOPUS:84888176261
SN - 1550-9389
VL - 9
SP - 1201
EP - 1205
JO - Journal of Clinical Sleep Medicine
JF - Journal of Clinical Sleep Medicine
IS - 11
ER -