Patients must be screened and educated
Serious adverse events can result when unauthorized family members, caregivers, or clinicians administer patient-controlled analgesia (PCA) for the patient "by proxy," warns a Sentinel Event Alert issued by the JCAHO.
Although the JCAHO’s Sentinel Event database contains only one medication error related to PCA by proxy, 6,069 reports of PCA errors have been submitted to U.S. Pharmacopeia in Rockville, MD. Of this number, 460 resulted in some level of harm to the patient, with five fatalities.
"The alert has given us some good suggestions about making our PCA process safer," explains Suzanne Compau, BSN, MHSA, director of patient safety at Gwinnett Hospital System in Lawrenceville, GA.
Here are key recommendations from the alert:
• Develop criteria for selecting appropriate patients to receive PCA and nurse-controlled analgesia.
Some patients may not be appropriate candidates to receive PCA because of their age, mental state, level of consciousness, psychological stability, or intellectual capacity, according to the alert.
"We have appointed the director of pharmacy and a nursing ad hoc committee to work with the chief of anesthesia on developing a checklist of criteria to determine appropriate candidates for PCA," says Angie King, BSN, CPHQ, quality management director at Tift Regional Medical Center in Tifton, GA. "It’s still too new to determine effectiveness, but we will be measuring outcomes and patient satisfaction."
The criteria still are a work in progress, says King. "We know that mental state prior to initiating treatment will be a factor, as well as assessment of patient comprehension," she says.
Appropriate screening of patients is an important safety mechanism, says Cindie Lou Roger, MSN, RN,BC, ANP,BC, AOCN, oncology/pain management clinical nurse specialist at Gwinnett, and co-chair of the organization’s pain committee.
"A well-meaning daughter might recognize that her elderly mother is in pain faster than a nurse, but if that patient is not competent, then they shouldn’t have a PCA." Instead, family members should alert nurses that the patient needs pain relief so that a proper assessment can be done and the right dosage given, she adds.
• 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, according to the alert.
• Teach patients and family members about the proper use of PCA.
The alert recommends giving written instructions to family members about the dangers of others pressing the button for the patient, and alerting staff to the dangers of administering a dose for the patient outside of a nurse-controlled analgesia protocol.
At Tift Regional, a question will be added to the organization’s patient satisfaction surveys asking patients, "Did you have a PCA pump, and did you feel it was adequately explained?"
PCA by proxy currently is not permitted at Gwinnett, Compau reports.
"Patients and families are educated at the time PCA is started and are warned against anyone but the patient activating the PCA button," she says. "Although discussion has arisen from time to time about allowing nurses to perform PCA by proxy for certain situations, we have not implemented such a protocol because of the very safety concerns outlined in the alert."
Roger plans to investigate current research on whether PCA by proxy can be done safely. "But for the time being, it’s a no-go here until we know more about it," she says.
Currently, IV pain medications only are given in these ways: PCA by self-administration, nurse-administered PRN bolus injections, or continuous infusions for end-of-life patients as per physician orders, Roger explains.
Patient education materials will be revised to specifically state that no one but the patient should push the button, she continues. "Previously, it’s just been verbal instructions; but considering the alert, we need to have a more formal process in place."
In addition, the organization’s policy will be revised to specifically state that PCA by proxy is not permitted, and this policy will be added to the mandatory annual competencies of nursing staff.
• Consider placing warning tags on all PCA delivery pendants or warning signs in areas where PCA therapy is used.
At Gwinnett, signs will be placed on PCA pumps stating, "Only patients should press this button."
"When educating the patient right after surgery, they may not hear everything that you are saying," Roger adds. "Just a simple label being placed on the pump would further instruct them."
[For more on the Sentinel Event Alert, contact:
• Suzanne Compau, BSN, MHSA, Director, Patient Safety, Gwinnett Hospital System, 1000 Medical Center Blvd., Lawrenceville, GA 30045. Phone: (678) 442-4683. Fax: (770) 682-2257. E-mail: SCompau@ghsnet.org.
• Angie King, BSN, CPHQ, Quality Management Director, Tift Regional Medical Center, 901 E. 18th St., Tifton, GA 31794. Phone: (229) 386-6119. Fax: (229) 556-6390. E-mail: email@example.com.
• Cindie Lou Roger, MSN, RN,BC, ANP,BC, AOCN, Oncology/Pain Management, Clinical Nurse Specialist, Gwinnett Hospital System, 1000 Medical Center Blvd., Lawrenceville, GA 30045. Phone: (678) 442-4267. E-mail: CLRoger@ghsnet.org.]