Think Smart to Improve the Safety of Patient-Controlled Analgesia

How often do errors with patient-controlled analgesia occur? More often than we know, research suggests.

Researchers who studied more than 900,000 medication record errors say that the 1% of errors related to patient-controlled analgesia (PCA) is probably just the tip of the iceberg. Although 1% may seem insignificant, this analysis was based on the voluntary medication error reporting, says lead researcher Rodney Hicks, Ph.D., who at that time of the study was manager, patient safety research and practice, U.S. Pharmacopeia.

"Although generalization of voluntary reported findings to the general population should be done cautiously," he points out, that "the general rule of thumb is that for every reported event, there can be between 300-1,000 unreported events."

This rule of thumb, based on 9,571 reported events, would mean that between 2.8 million and 9.6 million total events (unreported & reported) occurred over the 5-year period from July 1, 2000, to June 30, 2005. On an annualized basis, this would mean that about 600,000-2 million events/year could involve PCA.

These numbers are unacceptable in what should be an era of increasing patient safety. Says Dr. Hicks, "Further study would need to be done to ascertain the total number of PCA events, but the problem is extensive in my opinion." The picture is already pretty clear, but there is more to the data.

When the study looked at the number of events that caused harm, there were 624 records of PCA associated with harm, corresponding to 6.5% of the patients. Again, while 6.5% may seem small, as the study found, "By comparison, during the same period, only 1.5% of all other errors reported to MedMarx led to harm. This represents a fourfold higher relative risk of harm for PCA events."

"All health care disciplines were implicated in the errors, including physicians, pharmacists, and nurses" he said. "Therefore, it will take an interdisciplinary team to resolve the problems."

Dr. Hicks’ retrospective study of the magnitude, frequency, and nature of nonharmful and harmful medication errors associated with patient-controlled analgesia covered a 5-year review period with 919,241 medication errors records from 801 reporting health care facilities. The analysis was based on the international voluntary medication error reporting program, MedMarx. Dr. Hicks is now a professor a Western University College of Graduate Nursing, Pomona, Calif.

"Our analysis was in no means trying to discourage the use of PCA pumps. Many studies have shown the benefits of using PCA, including improved pain management, better utilization of nursing resources, increased patient satisfaction, and improved pulmonary function.

"However, this is clearly an indication that standardization needs to occur and organizations should invest in training and policies and procedures as well as equipment – all areas to promote safety."

Moreover, although elimination of error is critical, studies have shown even a correctly programmed PCA pump poses patient safety risks.

Appropriate doses of opiates can suppress respiration and decrease heart rate and blood pressure. Episodes of bradypnea and desaturation can escalate to respiratory depression requiring rescue, according to come via Ray Maddox, Pharm. D., of St. Joseph’s/Candler Health System and his colleagues, who studied an intravenous infusion safety initiative at the 644-bed, tertiary-care, magnet system to evaluate how "smart" technology can help avert high-risk adverse drug events and improve patient outcomes.

These investigators further point out that the success rate for in-hospital cardiopulmonary resuscitation remains less than one in five patients. If detected early, most cases of opioid-induced respiratory depression can be treated with naloxone. However, severe cases can be fatal. The risk of patient harm from medication errors with PCA pumps is 3.5 times the risk from any other type of medication administration error.

The researchers recommend the following: "Capnographic monitoring – measurements of ventilation using respiration and exhaled carbon dioxide – is particularly important because it can provide an earlier warning of respiratory depression than pulse oximetry in some patient populations."

In short, although there are many benefits to PCA usage, for improved patient safety, reduce the risks and monitor continuously to detect respiratory depression events.

With the desire to reduce errors and improve patient safety with the use of patient-controlled analgesia, a safety checklist is being developed by the Physician-Patient Alliance for Health and Safety. For more on this initiative, contact Michael Wong [email protected].

The Physician-Patient Alliance for Health & Safety is an advocacy group devoted to improving patient health and safety. PPAHS comprises physicians, patients, individuals, and organizations. PPAHS reports having no financial conflicts of interest and not having received funding or grants. It recently conducted a survey on the American Society of Anesthesiologists Standards & Anesthesia Patient Safety Foundation Recommendations, available online. PPAHS welcomes inquiries regarding financial assistance to implement the safety checklist initiative.

How often do errors with patient-controlled analgesia occur? More often than we know, research suggests.

Researchers who studied more than 900,000 medication record errors say that the 1% of errors related to patient-controlled analgesia (PCA) is probably just the tip of the iceberg. Although 1% may seem insignificant, this analysis was based on the voluntary medication error reporting, says lead researcher Rodney Hicks, Ph.D., who at that time of the study was manager, patient safety research and practice, U.S. Pharmacopeia.

"Although generalization of voluntary reported findings to the general population should be done cautiously," he points out, that "the general rule of thumb is that for every reported event, there can be between 300-1,000 unreported events."

This rule of thumb, based on 9,571 reported events, would mean that between 2.8 million and 9.6 million total events (unreported & reported) occurred over the 5-year period from July 1, 2000, to June 30, 2005. On an annualized basis, this would mean that about 600,000-2 million events/year could involve PCA.

These numbers are unacceptable in what should be an era of increasing patient safety. Says Dr. Hicks, "Further study would need to be done to ascertain the total number of PCA events, but the problem is extensive in my opinion." The picture is already pretty clear, but there is more to the data.

When the study looked at the number of events that caused harm, there were 624 records of PCA associated with harm, corresponding to 6.5% of the patients. Again, while 6.5% may seem small, as the study found, "By comparison, during the same period, only 1.5% of all other errors reported to MedMarx led to harm. This represents a fourfold higher relative risk of harm for PCA events."

"All health care disciplines were implicated in the errors, including physicians, pharmacists, and nurses" he said. "Therefore, it will take an interdisciplinary team to resolve the problems."

Dr. Hicks’ retrospective study of the magnitude, frequency, and nature of nonharmful and harmful medication errors associated with patient-controlled analgesia covered a 5-year review period with 919,241 medication errors records from 801 reporting health care facilities. The analysis was based on the international voluntary medication error reporting program, MedMarx. Dr. Hicks is now a professor a Western University College of Graduate Nursing, Pomona, Calif.

"Our analysis was in no means trying to discourage the use of PCA pumps. Many studies have shown the benefits of using PCA, including improved pain management, better utilization of nursing resources, increased patient satisfaction, and improved pulmonary function.

"However, this is clearly an indication that standardization needs to occur and organizations should invest in training and policies and procedures as well as equipment – all areas to promote safety."

Moreover, although elimination of error is critical, studies have shown even a correctly programmed PCA pump poses patient safety risks.

Appropriate doses of opiates can suppress respiration and decrease heart rate and blood pressure. Episodes of bradypnea and desaturation can escalate to respiratory depression requiring rescue, according to come via Ray Maddox, Pharm. D., of St. Joseph’s/Candler Health System and his colleagues, who studied an intravenous infusion safety initiative at the 644-bed, tertiary-care, magnet system to evaluate how "smart" technology can help avert high-risk adverse drug events and improve patient outcomes.

These investigators further point out that the success rate for in-hospital cardiopulmonary resuscitation remains less than one in five patients. If detected early, most cases of opioid-induced respiratory depression can be treated with naloxone. However, severe cases can be fatal. The risk of patient harm from medication errors with PCA pumps is 3.5 times the risk from any other type of medication administration error.

The researchers recommend the following: "Capnographic monitoring – measurements of ventilation using respiration and exhaled carbon dioxide – is particularly important because it can provide an earlier warning of respiratory depression than pulse oximetry in some patient populations."

In short, although there are many benefits to PCA usage, for improved patient safety, reduce the risks and monitor continuously to detect respiratory depression events.

With the desire to reduce errors and improve patient safety with the use of patient-controlled analgesia, a safety checklist is being developed by the Physician-Patient Alliance for Health and Safety. For more on this initiative, contact Michael Wong [email protected].

The Physician-Patient Alliance for Health & Safety is an advocacy group devoted to improving patient health and safety. PPAHS comprises physicians, patients, individuals, and organizations. PPAHS reports having no financial conflicts of interest and not having received funding or grants. It recently conducted a survey on the American Society of Anesthesiologists Standards & Anesthesia Patient Safety Foundation Recommendations, available online. PPAHS welcomes inquiries regarding financial assistance to implement the safety checklist initiative.

How often do errors with patient-controlled analgesia occur? More often than we know, research suggests.

Researchers who studied more than 900,000 medication record errors say that the 1% of errors related to patient-controlled analgesia (PCA) is probably just the tip of the iceberg. Although 1% may seem insignificant, this analysis was based on the voluntary medication error reporting, says lead researcher Rodney Hicks, Ph.D., who at that time of the study was manager, patient safety research and practice, U.S. Pharmacopeia.

"Although generalization of voluntary reported findings to the general population should be done cautiously," he points out, that "the general rule of thumb is that for every reported event, there can be between 300-1,000 unreported events."

This rule of thumb, based on 9,571 reported events, would mean that between 2.8 million and 9.6 million total events (unreported & reported) occurred over the 5-year period from July 1, 2000, to June 30, 2005. On an annualized basis, this would mean that about 600,000-2 million events/year could involve PCA.

These numbers are unacceptable in what should be an era of increasing patient safety. Says Dr. Hicks, "Further study would need to be done to ascertain the total number of PCA events, but the problem is extensive in my opinion." The picture is already pretty clear, but there is more to the data.

When the study looked at the number of events that caused harm, there were 624 records of PCA associated with harm, corresponding to 6.5% of the patients. Again, while 6.5% may seem small, as the study found, "By comparison, during the same period, only 1.5% of all other errors reported to MedMarx led to harm. This represents a fourfold higher relative risk of harm for PCA events."

"All health care disciplines were implicated in the errors, including physicians, pharmacists, and nurses" he said. "Therefore, it will take an interdisciplinary team to resolve the problems."

Dr. Hicks’ retrospective study of the magnitude, frequency, and nature of nonharmful and harmful medication errors associated with patient-controlled analgesia covered a 5-year review period with 919,241 medication errors records from 801 reporting health care facilities. The analysis was based on the international voluntary medication error reporting program, MedMarx. Dr. Hicks is now a professor a Western University College of Graduate Nursing, Pomona, Calif.

"Our analysis was in no means trying to discourage the use of PCA pumps. Many studies have shown the benefits of using PCA, including improved pain management, better utilization of nursing resources, increased patient satisfaction, and improved pulmonary function.

"However, this is clearly an indication that standardization needs to occur and organizations should invest in training and policies and procedures as well as equipment – all areas to promote safety."

Moreover, although elimination of error is critical, studies have shown even a correctly programmed PCA pump poses patient safety risks.

Appropriate doses of opiates can suppress respiration and decrease heart rate and blood pressure. Episodes of bradypnea and desaturation can escalate to respiratory depression requiring rescue, according to come via Ray Maddox, Pharm. D., of St. Joseph’s/Candler Health System and his colleagues, who studied an intravenous infusion safety initiative at the 644-bed, tertiary-care, magnet system to evaluate how "smart" technology can help avert high-risk adverse drug events and improve patient outcomes.

These investigators further point out that the success rate for in-hospital cardiopulmonary resuscitation remains less than one in five patients. If detected early, most cases of opioid-induced respiratory depression can be treated with naloxone. However, severe cases can be fatal. The risk of patient harm from medication errors with PCA pumps is 3.5 times the risk from any other type of medication administration error.

The researchers recommend the following: "Capnographic monitoring – measurements of ventilation using respiration and exhaled carbon dioxide – is particularly important because it can provide an earlier warning of respiratory depression than pulse oximetry in some patient populations."

In short, although there are many benefits to PCA usage, for improved patient safety, reduce the risks and monitor continuously to detect respiratory depression events.

With the desire to reduce errors and improve patient safety with the use of patient-controlled analgesia, a safety checklist is being developed by the Physician-Patient Alliance for Health and Safety. For more on this initiative, contact Michael Wong [email protected].

The Physician-Patient Alliance for Health & Safety is an advocacy group devoted to improving patient health and safety. PPAHS comprises physicians, patients, individuals, and organizations. PPAHS reports having no financial conflicts of interest and not having received funding or grants. It recently conducted a survey on the American Society of Anesthesiologists Standards & Anesthesia Patient Safety Foundation Recommendations, available online. PPAHS welcomes inquiries regarding financial assistance to implement the safety checklist initiative.