Standards FAQ Details | Joint Commission
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Sunday 11:55 CST, February 7, 2016

Standards FAQ Details


Human Resources (HR) (Critical Access Hospitals / Critical Access Hospitals)

Permission to Administer Moderate Sedation
Updated | July 07, 2010
Q: Are specific privileges to administer sedation required?

  A: The anesthesia care standards in each manual require that the individuals who are "permitted" to administer sedation are able to rescue patients at whatever level of sedation or anesthesia is achieved either intentionally or unintentionally, e.g., when the patient slips from moderate into deep sedation or from deep sedation into full anesthesia. Each organization is free to define how it will determine that the individuals are able to perform the required types of rescue. Acceptable examples include, but are not limited to, ACLS certification, a satisfactory score on a written examination developed in concert with the department of anesthesiology, a mock rescue exercise evaluated by an anesthesiologist.   With regard to licensed independent practitioners who administer conscious sedation it is not required that criteria for competence to perform "moderate" sedation be included in a separately delineated privilege. For example, competency criteria for "moderate" sedation may be defined and included in procedure-based privileges. Thus, a clinical privilege for endoscopy could be defined as including the use of sedation. Organizations decide whether to use privileging as an appropriate approach to take based on the education, training, and experience of the clinicians requesting authorization perform procedures using sedation.   With regard to non-Licensed Independent Practitioners, such as nurses, who are permitted to administer the sedation, the permission could be found in the individual's job description, or other documentation in their personnel file.