Patient Harm 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."