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Physician-Patient Alliance for Health & Safety: Hospitals Need to Address PCA Pump Patient Safety

CHICAGO, March 21, 2012  /PRNewswire/ -- For patient safety, PPAHS encourages continuous electronic monitoring, including the use of both capnography and pulse oximetry, of all patients using patient-controlled analgesia (PCA).

According to the Institute for Safe Medication Practices (ISMP), the technology and knowledge exist today to prevent errors associated with use of patient-controlled analgesia. As ISMP Vice President Judy Smetzer says, "The solutions are available. We know how to prevent these errors, while preserving the benefits of this patient-centered technology."

Accordingly, states ISMP President Michael Cohen, "Hospitals need to address the causes of PCA errors now. Appropriate education of patients, family members, and hospital staff is key."

Despite these statements by ISMP and many other patient safety and medical organizations, questions persist about how often PCA errors occur, whether existing medical practices are sufficient, and what can be done about PCA errors.

So, to answer some of these questions, Michael Wong of the Physician-Patient Alliance for Health & Safety interviewed Tim Ritter (Senior Patient Safety Analyst at the Pennsylvania Patient Safety Authority) and Matthew Grissinger (Director, Error Reporting Programs at ISMP).

Some key comments from the interview include:

Ritter discussing the number of errors that occur with PCA, "Over the six-year period from June 2004 to May 2010, data collected by Pennsylvania Patient Safety Authority revealed that there were approximately 4,500 reports associated with PCA pumps. Moreover, U.S. Food and Drug Administration's (FDA) Manufacturer and User Device Experience (MAUDE) database demonstrates that PCA-related device events are three times as likely to result in injury or death as reports of device events involving general-purpose infusion pumps."

Grissinger discussing why periodic caregiver checks and pulse oximetry are not sufficient, "... a "periodic check" and pulse oximetry would only catch an error, not prevent the error ... there's too much reliance on pulse oximetry readings, which can offer a false sense of security since oxygen saturation is usually maintained even at low respiratory rates, especially if supplemental oxygen is in place."

For a complete copy of the interview, please go to:

About Physician-Patient Alliance for Health & Safety

Physician-Patient Alliance for Health & Safety is an advocacy group devoted to improving patient health and safety. PPAHS is composed of physicians, patients, individuals, and organizations. Our website is

SOURCE Physician-Patient Alliance for Health & Safety
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