Standards FAQ Details | Joint Commission
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Wednesday 3:15 CST, February 21, 2018

Standards FAQ Details


Privileges - Administration of Moderate Sedation
Modify | April 11, 2016
Are specific privileges to administer sedation required?

While privileges are required to administer sedation (see MS.3.01.01 EP 2), 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.  Individuals who are privileged to administer sedation must be 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.

Organization must define how it will determine that the individuals are competent to perform the required types of rescue. Acceptable examples may include, but are not limited to, ACLS certification, a satisfactory score on a written examination developed in concert with the department of anesthesiology (see LD.04.01.05 EP 7), a mock rescue exercise evaluated by an anesthesiologist, etc.

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