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Physician-Patient Alliance for Health & Safety: Monitoring Technology for PCA Pumps Can Prevent Adverse Events: So Why Are Hospitals Not Using It?

CHICAGO, May 8, 2012 /PRNewswire/ -- Adverse events with PCA pumps may occur even without an error being committed by attending healthcare professionals.

As Frank Federico, RPh (Executive Director at the Institute for Healthcare Improvement) points out, "Many patients may experience harm even with appropriate dosing of narcotics. This is a critical point for patients, their families and their caregivers to know -- a patient may experience respiratory depression, leading to death, even if the PCA pump has been programmed correctly. Many believe that some of the adverse effects are the cost of doing business. Our goal should be to reduce all harm, understanding that we may not know how to today. When a patient dies from respiratory depression, the toll on the patient's family, friends, and community are enormous. The cost of adverse events goes beyond the costs associated with a medial malpractice claim.   

In their study, "Programming errors contribute to death from patient-controlled analgesia: case report and estimate of probability," researchers determined that mortality from programming errors with PCA pumps was estimated to be a low-likelihood event (ranging from 1 in 33,000 to 1 in 338,800), but relatively high in absolute terms (ranging from 65 to 667 deaths). In other words, when harm from PCA occurs, it is likely to result in death.

Moreover, when PCA pump events were correlated against costs, quite understandably, non-harmful events were estimated to cost about $28 per event, but a harmful adverse event determined to be opioid related was $13,803 per event, as the study, "The Rate and Costs Attributable to Intravenous Patient-Controlled Analgesia Errors" showed.

As Rodney Hicks, PhD (Professor, Western University College of Graduate Nursing, Pomona, California), says, "Our study highlighted that IV PCA has a higher likelihood of errors, because of the complexity of IV PCA administration. Practitioners should capitalize on capnography and future innovations, such as linking monitoring alarms to the hospital's network, to alert staff when a patient may be experiencing respiratory depression. Using such technology will realize potential cost savings or avert future costs associated with adverse events with PCA pump."

Steps taken by Veterans Health Administration to avert PCA events echo these sentiments. As Bryanne Patail, biomedical engineer at the U.S. Department of Veterans Affairs, National Center for Patient Safety describes how VHA implemented a "strong fix" to reduce PCA-related events by more than 60%:

Use of PCA pumps is a process, and improving that process is an area that involves many stakeholders. In looking at fixes, they can be categorized as strong, intermediate or weak fixes. The strongest fix for PCA pumps is a forcing function, such as an integrated end tidal CO2 monitor that will pause the pump if a possible over infusion occurred. So, healthcare providers should first look at these strong fixes. There they will see the most impact on reducing errors and improving patient safety.

For more on this safety issue and commentary by David Watson (VP at ECRI Institute) and Dr. Robert Stoelting (President, Anesthesia Patient Safety Foundation), please see:

About Physician-Patient Alliance for Health & Safety

Physician-Patient Alliance for Health & Safety is an advocacy group devoted to improving patient health and safety. Our website is

PPAHS is currently developing a checklist targeting PCA pump use. For more on this initiative, please see this ASC Review article:

SOURCE Physician-Patient Alliance
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