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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?
Date:5/8/2012

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
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SOURCE Physician-Patient Alliance
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