Mother Dies While Undergoing Outpatient Procedure

She was scheduled for an endoscopic retrograde cholangiopancretography which involves the removal and replacement of a stent in the biliary tree, which transports fluid secreted by the liver into the small intestine.

The anesthesia plan was to use moderate sedation, but she was over-medicated during the procedure which resulted in the cessation of her breathing. The caregivers were slow to recognize her deteriorating condition or its cause. When her lack of breathing and resulting severe hypoxia was finally recognized, a code blue was called. The code team misinterpreted electrical activity in her heart and failed to perform chest compressions as part of the cardiopulmonary resuscitation (CPR) to ensure that blood was being circulated through her. The team’s failure to perform appropriate CPR resulted in both the heart and the brain not receiving adequate oxygen, and she suffered severe hypoxic brain damage. She died on April 25, 2008 without regaining consciousness.

It is crucial that health care providers receive adequate education and training before performing Moderate Sedation. Our latest CE course was designed to educate those healthcare personnel responsible for performing Moderate Sedation.

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