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Posted: December 23, 2008

Patients Often Harmed When Administering Their Own Pain Medication

Allowing patients to control their own pain medication intravenously is risky business because the patient is four times more likely to harm themselves than if other forms of medication were used, a new study says. 

The report, published in The Joint Commission Journal on Quality and Patient Safety, shows that most mistakes involving intravenous patient-controlled analgesia (PCA) resulted from human error, equipment issues or communication problems that led to the patient receiving the wrong dosage or drug. PCA errors also tended to be more severe – causing harm to patients and requiring clinical interventions -- than other types of medication errors.


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The study examined more than 9,500 PCA errors occurring over a five-year period in the United States. It showed that patient harm occurred in 6.5% of the incidents, compared to 1.5% for general medication errors.


Most of the PCA errors involved either the wrong dosage or the wrong drug. For example, one case involved a patient who received several 10mg 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, Ph.D., of the Texas Tech University Health Sciences Center in 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. Health care organizations should now plan to make the process safer." 

Through this method, a patient can administer doses of pain medication with the push of a button. A computerized pump that contains a syringe of doctor-prescribed pain medication is connected directly to a patient's intravenous (IV) line. PCA can be used to relieve pain after surgery or for other chronic pain conditions. Harm associated with PCA errors can include respiration suppression, inadequate pain relief and patient death. 

Data for the study came from voluntary reports to the United States Pharmacopeia (USP)'s MEDMARX Program, and shows that more than 60% of the hospitals anonymously reporting medication errors through MEDMARX had at least one PCA error.


To reduce PCA errors, Hicks and his co-authors recommend three strategies: 

  1. 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.
  2. 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.
  3. 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. 

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