Navigation Links
Study: Patient Harm More Common with Patient-Controlled Pain Medication
Date:12/1/2008

OAKBROOK, Ill., Dec. 1 /PRNewswire-USNewswire/ -- 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 (www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_33.htm) 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: http://www.ingentaconnect.com/content/jcaho/jcjqs

To subscribe to The Joint Commission Journal on Quality and Patient Safety, please call JCR Customer Service toll-free at 800-746-6578, or visit www.jcrinc.com.

Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission. JCR educational programs and publications support the accreditation activities of The Joint Commission, but are separate functions. Attendees at JCR educational programs and purchasers of JCR publications receive no special consideration or treatment in, or confidential information about, the accreditation process. Learn more about Joint Commission Resources at www.jcrinc.com.


'/>"/>
SOURCE The Joint Commission
Copyright©2008 PR Newswire.
All rights reserved

Related medicine news :

1. Study: Childhood constipation just as serious as asthma
2. Study: Want to be happier? Be more grateful
3. Study: Smoking Ban Would Help Reduce Heart Attack Admissions
4. New study: A Common Class of GI Medications Reduce Protection Against Heart Attack in Patients Taking Widely Prescribed Cardiovascular Drug
5. University of Illinois - Chicago Study: Raisins Contain Compounds that May Inhibit Cavity-causing Bacteria
6. Geisinger study: Increasing health care value improves health care quality
7. UNC study: Parenting can override effect of genes in how babies respond to stress
8. Study: Delaying evolution of drug resistance in malaria parasite possible
9. U. of Chicago study: More than 10 percent of older Americans suffer mistreatment
10. UNC study: chilling hardship rates among families raising disabled children
11. UNC study: Two-thirds of severe sports injuries to female students due to cheerleading
Post Your Comments:
*Name:
*Comment:
*Email:
(Date:6/25/2016)... ... ... On Friday, June 10, Van Mitchell, Secretary of the Maryland Department of ... recognition of their exemplary accomplishments in worksite health promotion. , The Wellness at Work ... Symposium at the BWI Marriott in Linthicum Heights. iHire was one of 42 businesses ...
(Date:6/24/2016)... (PRWEB) , ... June 24, 2016 , ... Those who ... with these feelings, many turn to unhealthy avenues, such as drug or alcohol abuse, ... Marne, Michigan, has released tools for healthy coping following a traumatic event. , Trauma ...
(Date:6/24/2016)... , ... June 24, 2016 , ... ... and Scientific Sessions in Dallas that it will receive two significant new grants ... grants came as PHA marked its 25th anniversary by recognizing patients, medical professionals ...
(Date:6/24/2016)... Diego, CA (PRWEB) , ... June 24, 2016 , ... ... with the American Cancer Society and the Road To Recovery® program to drive cancer ... to seniors and other adults to ensure the highest quality of life and ongoing ...
(Date:6/24/2016)... ... June 24, 2016 , ... EB Medicine ... Making in Emergency Medicine conference in Ponte Vedra Beach, FL. The awards honor ... Emergency Medicine Practice and Pediatric Emergency Medicine Practice. , “With this ...
Breaking Medicine News(10 mins):
(Date:6/24/2016)... N.C. , June 24, 2016  Consumers ... decisions and regulators/payers have placed more emphasis on ... environment, patient support programs in the pharmaceutical industry ... patients, medications. Consequently, pharmaceutical companies are focusing on ... they are providing products and services that improve ...
(Date:6/24/2016)... -- Research and Markets has announced ... Applications, Technologies, Forecasts" report to their offering. ... Smart Skin, Structural Health Monitoring, Composite Smart Structures, ... involves electronic and/or electrical components and circuits that ... such as vehicle bodies or conformally placed upon ...
(Date:6/24/2016)... According to a new market ... Needles, Safety Pen Needles), Needle Length (4mm, 5mm, 6mm, ... of Purchase (Retail, Non-Retail) - Trends & Global Forecasts ... market for the forecast period of 2016 to 2021. ... by 2021 from USD 1.65 Billion in 2016, growing ...
Breaking Medicine Technology: