Study shows PCA results in more medication errors

Wrong dose, wrong drug cited most often

Intravenous patient-controlled analgesia (PCA) improves pain control for most patients, but a recent study1 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% of incidents, compared to 1.5% 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, PhD., MSN, MPA, 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."

The authors recommend three strategies to reduce PCA errors:

• 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.

Reference

1. Hicks RW, Heath WM, Sikirica V, et. al. Medication Errors Involving Patient-Controlled Analgesia. Joint Commission Journal on Quality and Patient Safety 2008; 34:734-742(9).