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

tains 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 '/>"/>

SOURCE The Joint Commission
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