Patient harm more common with patient-controlled pain medication

Intravenous patient-controlled analgesia (PCA) allows patients to control their own pain medication, but a new study published in the December 2008 issue of The Joint Commission Journal on Quality and Patient Safety shows that errors related to this practice are four times more likely to result in patient harm than errors that occur with other medications.

The study of more than 9,500 PCA errors over a five-year period in the United States showed that patient harm occurred in 6.5 percent of incidents, compared to 1.5 percent for general medication errors. The PCA errors examined also were more severe -- harming patients and requiring clinical interventions in response to the error -- than other types of medication errors. Most errors involved either the wrong dosage or the wrong drug caused by human factors, equipment or communication breakdowns. For example, one case involved a patient who received several 10 mg doses instead of 1 mg medication doses after surgery because of an incorrectly programmed dispensing pump. The PCA errors examined also were more severe -- harming patients and requiring clinical interventions in response to the error -- than other types of medication errors.

"The entire PCA process is highly complex," says the study's lead author Rodney W. Hicks, Ph.D., M.S.N., M.P.A., UMC Health System Endowed Chair for Patient Safety and Professor, Anita Thigpen Perry School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas. "PCA orders must be written, reviewed and then accurately programmed into sophisticated delivery devices for patients to be pain free. Such complexity makes PCA an error prone process. Health care organizations should now plan to make the process safer."

Through this method, a patient can administer doses of pain medication with the push of a button. A computerized pump that contains a syringe of doctor-prescribed pain medication is connected directly to a patient's intravenous (IV) line. PCA can be used to relieve pain after surgery or for other chronic pain conditions. Harm associated with PCA errors can include respiration suppression, inadequate pain relief and patient death.

Data for the study came from voluntary reports to the United States Pharmacopeia (USP)'s MEDMARX Program, and shows that more than 60 percent of the hospitals anonymously reporting medication errors through MEDMARX had at least one PCA error. The study -- "Medication Errors Involving Patient-Controlled Analgesia" -- is important because preventing PCA errors "would yield substantial gains in patient safety," the authors conclude.

To reduce PCA errors, Dr. Hicks and the co-authors recommend three strategies:

• Simplify the technical equipment used in PCA. The study shows that the PCA process is heavily dependent on the ability of caregivers to execute sequential tasks successfully, so easy-to-follow setup instructions for equipment could reduce errors. The study urges PCA vendors to look for ways to make it less likely that programming errors will lead to a wrong dose.
• Use bar codes and an electronic medication administration record to reduce errors that involve the wrong medication. Independent double-checks of the PCA orders, the product and the PCA device settings should be standard practice, the study advises.
• Ask pharmacists to design easily understood and standardized forms for PCA, and ensure that prescribers use only these standardized forms. These actions would address communication problems that lead to errors and bring regional standardization to the PCA process.  

In 2004 The Joint Commission issued a Sentinel Event Alert that identified root causes of patient-controlled analgesia errors and contained recommendations for reducing errors.

The Joint Commission Journal on Quality and Patient Safety, published monthly by Joint Commission Resources, features peer-reviewed research and case studies on improving quality and safety in health care organizations. Click here to order this article in the December 2008 issue.

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