JCAHO: Patient-controlled analgesia overuse warning

Patient-controlled analgesia (PCA) is a well-accepted method of delivering pain relief, but JCAHO is warning that well-intended family members and caregivers may be putting patients at risk by becoming involved in administering patient-controlled analgesia. JCAHO urges risk managers to implement policies and procedures that will discourage anyone other than the patient from administering the pain medication.

PCA uses a computerized pump that is hooked up to the patient’s intravenous line, allowing the patient to receive the pain medication by pressing a button. PCA provides the individual greater control in managing the pain, but the patient provides a built-in safety check in this system because an oversedated patient is not able to push the button to cause a harmful or even fatal overdose. JCAHO cautions that problems can arise, however, when a family member or health care professional bypasses that important safety feature by administering PCA.

This is called "PCA by proxy." In a recent Sentinel Event Alert, JCAHO president Dennis S. O’Leary, MD, said, "PCA by proxy errors are readily preventable and can be virtually eliminated through timely and appropriate education and training of staff and family members." Risk managers can read between the lines for an important warning: JCAHO considers this a hazard that is "readily preventable" and which can be "virtually eliminated" with staff training. That means JCAHO is likely to take a hard line when assessing a PCA by proxy death or injury at your hospital.

(The entire Sentinel Event Alert is available on-line at www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_33.htm.)

Nurse responsible for one by proxy death

Working with the United States Pharmacopeia (USP) and the Institute for Safe Medication Practices (ISMP), JCAHO has developed guidelines for avoiding PCA by proxy. The first challenge, according to ISMP president Michael Cohen, RPh, MS, ScD, is overcoming the urge to provide more pain relief to someone who is suffering.

"PCA by proxy errors are usually the direct result of family members or health care professionals administering doses for the patient, with the intent of keeping them comfortable," he says. "This well-intentioned effort can result in oversedation, respiratory depression, and even death."

JCAHO reports that its database contains only one medication error related to PCA by proxy. However, reports submitted to the USP medication errors databases revealed a combined total of 6,069 PCA errors. Of this number, 460 resulted in fatality or some level of harm to the patient-impairment of the physical, emotional, psychological function or structure of the body and/or pain resulting there/from. Fifteen of the 460 cases were the direct result of PCA error by proxy — 12 cases attributed to family members, two to a nurse and one to a pharmacist, JCAHO reports.

Five of the 460 errors were fatal errors, including one by proxy error attributed to a nurse.

Most incidents occur in hospitals

The setting or location of the error was not identified in all cases, but 401 of the 460 cases occurred within the hospital with the majority of errors experienced in the patient care units. Other sites within the hospital included the post-anesthesia care unit, inpatient pharmacy, intensive care unit (surgical, medical, coronary/adult, pediatric and neonatal), oncology department, pediatric unit, maternity and labor and delivery unit, the operating room, outpatient surgery unit, endoscopy/GI lab, and preoperative holding area.

Cohen notes that it is not always improper for a nurse to administer PCA, in some situations in which the patient is unable to do so. But that use of PCA requires protocols and appropriate assessment tools to gauge the level of pain, sedation, and respiratory status, he cautions.

The ISMP reports that contributing factors in PCA by proxy errors involving health care professionals may include improper patient selection, inadequate patient monitoring, and insufficient training or education related to the selection of drugs, dosing, lockout periods and infusion devices.

Five policies to implement

The ISMP, USP, and JCAHO devised recommendations for how health care providers can avoid PCA by proxy incidents. The entire recommendations are in the Sentinel Event Alert on the JCAHO web site, but this is a summary:

1. Develop criteria for selecting appropriate patients to receive PCA and nurse-controlled analgesia.

This criteria-based selection process should consider the risk that PCA by proxy might occur. Some patients may not be appropriate candidates to receive PCA because of their age (infants and young children are not appropriate candidates); their mental state (confusion, agitation, restlessness); or due to their level of consciousness, psychological stability, or intellectual capacity.

2. Carefully monitor patients.

Even at therapeutic doses, opiates can suppress respiration, heart rate and blood pressure, so the need for monitoring and observation is critical. Oximetry and/or capnography monitoring may be appropriate in some cases.

3. Teach patients and family members about the proper use of PCA and the dangers of others pressing the button for the patient. Provide written instructions to family members that instruct them NOT to administer PCA doses.

4. Alert staff to the dangers of administering a dose for the patient outside of a nurse controlled analgesia protocol.

5. Consider placing warning tags on all PCA delivery pendants that state, "Only the patient should press this button."

Alternatively, consider posting warning signs in all areas where PCA therapy is used that state, "Only the patient should press the PCA delivery pendant."