Avoid PCA errors with education, wise selection

Don’t let family members administer medication

Medication errors associated with patient-controlled analgesia (PCA) pumps most often are caused by inadequate patient and staff education, misuse by well-intentioned family members, and improper patient selection, according to results of a recent survey by the Institute for Safe Medication Practices in Huntingdon Valley, PA. "Although our survey was informal, the health care practitioners who responded identified a number of reasons for PCA errors," says Hedy Cohen, RN, BSN, MS, vice president of the nonprofit organization that reviews and provides education on medication errors and adverse events to the health care industry.

One of the most frequently cited practice-related problems is incorrect programming of the PCA pump, she says. Staff may misplace a decimal point, misread a prescription, or neglect to double-check settings before beginning infusion, Cohen reports. "It is essential that staff members not only receive initial training on the pump, but that they also be retested on the pump’s use frequently."

Because different brands of pumps require staff members to learn a variety of programming steps, it is best to choose one pump for the entire facility, Cohen adds. "It is not only more efficient but also more effective if your nurse has to learn how to program and how to teach the patient to operate only one pump," she says.

Another frequent reason for misuse of PCA pumps is a well-meaning family member, Cohen points out. One of a PCA pump’s safety features to prevent an overdose of medication is a lockout interval that prevents a patient from administering a dose within a certain time period, she says. "Patients are supposed to evaluate their own pain level and administer medication when they feel the need. This means that a drowsy, sedated patient won’t push the button for more medication."

Unfortunately, well-meaning family members or nurses may push the button and think that they are helping the patient avoid pain, when, in fact, they may be oversedating the patient, she says.

While PCA pumps are designed to prevent overmedication, this safety feature works effectively only when the patient is pushing the button, Cohen explains. If a patient already is drowsy or sedated from anesthesia or pain medication administered in the recovery area, the patient won’t push the button for more medication because he or she feels comfortable, she explains. If, however, a family member decides to push the button to help the patient avoid pain, the pump may administer the medication because the request for medication falls within proper time frames and doses, she says.

"This extra medication has resulted in oversedation, respiratory depression, and even death," Cohen adds. One way to avoid "PCA by proxy" is to hang a sign on every PCA pump that clearly states that the patient is the only person who should push the button, she suggests. "It’s also important to emphasize this fact to nurses in their own education and to family members during patient education."

Proper patient selection also is critical when determining who will use a PCA pump, adds Cohen. "The patient must be mentally alert and capable of managing his or her own pain in order to be issued a PCA pump," she says. When an infant, small child, or cognitively impaired elderly patient is assigned PCA, the staff are relying upon PCA by proxy, and that process often has errors associated with it, she adds.

PCA is an effective, safe way to control pain, Cohen explains. "The only problem is that we’ve become complacent because 99% of the time, there are no problems," she says. "We need to make sure we stay alert to the errors that can occur infrequently." 


A copy of the report on patient-controlled analgesia can be viewed at no cost on-line at www.ismp.org. Choose "Medication Safety Alerts" from the top navigational bar, then choose "Archives." The report is in two parts and appears in the July 10, 2003, and July 24, 2003, issues. For more about the ISMP Medication Safety Alert that reviews safety issues with patient-controlled analgesia, contact: The Institute for Safe Medication Practices, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006. Phone: (215) 947-7797. Fax: (215) 914-1492.

For a free review of patient-controlled analgesia pumps conducted by ECRI, a nonprofit health research organization in Plymouth Meeting, PA, go to: www.ecri.org and click on the "Patient Safety" button on the right side of the home page. Scroll down the left navigational bar to "Health Devices Alerts Special Reports," and choose JCAHO’s 2003 National Patient Safety Goal for Infusion Pump Free-Flow Protection: Assessing General-Purpose and Patient-Controlled Analgesic Pumps.