Safe Sedation Resources
Minimum Standards - Safe Procedural Sedation
Welcome to the Safe Procedural Sedation Project Resources page. The ACI Safe Sedation Working Group has developed the Minimum Standards for Safe Procedural Sedation. These Standards are intended to support the safe provision of non-anaesthetist administered sedation.
Minimum Standards (PDF file - 1.4 MB)
Self Assessment Tool
To improve the quality of sedation service in procedural unit/departments in each Local Health District, a self-assessment tool was developed to assess current practice against the Minimum Standards.
(XLSX file - 72.8 KB)
How to use the Self Assessment Tool
The excel spreadsheet has four tabs:

How to use this tab provides instructions

Questions tab details questions for procedural units/departments

Summary report tab includes a summary of the answers in the second tab and generates a list of corresponding actions

List tab provides some suggested actions which will assist the procural unit / department to meet the minimum standards
Observational Audit Tool
Procedural units/departments can also use the Observational Audit Tool to assess their practice. While the self assessment tool is used to summarise overall practice in the unit, the observational audit tool is used to assess practice during individual episodes of sedation care.
(XLSX file - 20.1 KB)
How to use the Observational Audit Tool

How to use this Tool tab provides instructions

Observational Audit Tool tab details questions for completion when observing an episode of procedural sedation

OAT guidance tab provides information to assist the person observing and completing the audit tool
Implementation Toolkit
The Minimum Standards will be implemented statewide in a coordinated approach to ensure that procedural departments in each Local Health District have the necessary tools and resources to provide safe provision of procedural sedation.
An implementation toolkit along with some draft tools has been developed to provide guidance with and assist standard implementation. The tools include pre procedure assessment form, and an intra/post procedure document.
Implementing the Minimum Standards will also support hospitals/LHDs to meet the requirements for level 3 procedures (with procedural sedation) outlined in the NSW Health Clinical Procedure Safety Policy. More information on the policy directive can be found on the CEC website.
(PDF file - 672.5 KB)
(PDF file - 246.6 KB)
(PDF file - 215.0 KB)
Procedural Sedation Infographic
(PDF file - 1.6 MB)
ACI Project Documents
- Safe Procedural Sedation Project: Phase 1 Diagnostic and Solution Design Report
- Safe Procedural Sedation Project: Phase 2 Diagnostic Report
Documentation and Forms Shared by Other Sites Across NSW
Nepean Blue Mountains Local Health District
Northern Sydney Local Health District
South Eastern Sydney Local Health District
Learning Packages
Central Coast Local Health District
- Sedation Safety in Central Coast LHD Endoscopy Units – Learning Package for Registered Nurses
Supplementary documents below: - Sedation Safety at Central Coast Health Sector Hospitals – Learning package for Registered Nurses
Supplementary documents below:
Nepean Blue Mountains Local Health District
- Nepean Hospital – Sedation Self Education Package
- Sedation Competency Assessment Tool
- Sedation Recovery Competency Assessment Tool
- Nepean Hospital - Learning Package for the Administration of Procedural Sedation in the Cardiac Catheter Lab
Mid North Coast Local Health District
- Clinician Airway Monitor Course – session powerpoint slides. Accompanying resources available on request.
Education and Training Courses
Policy, Procedure and Protocols
- PS09 – Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures
- Clinical Procedure Safety
Central Coast Local Health District
Other Resources
- STOP_BANG Questionnaire
- The Emergency Care Institute has developed tools specific to procedural sedation in the emergency department