CE: Original Research: Errors in Postoperative Administration of Intravenous Patient-Controlled Analgesia: A Retrospective Study

Abstract

Background: Intravenous patient-controlled analgesia (IV PCA), which typically involves opioids, has become widely used in clinical settings as an effective method of pain management. Identifying errors in the administration of these drugs is essential to improving patient outcomes. This study sought to describe and analyze the errors associated with postoperative IV PCA. Methods: Relevant data were collected from the medical records of all patients who received IV PCA at a large academic medical center in South Korea during a three-year period. The study sample comprised 45,104 patients who used one of four types of IV PCA delivery devices. Results: Errors occurred in 406 cases (0.9%). Operator error was the most common type of error (54.7%), followed by device malfunction (32.3%), prescription error (12.3%), and patient error (0.7%). Of the 222 operator errors, the most frequent type was failure to begin IV PCA drug administration (28.8%), followed by programming errors by non-anesthesia providers who weren't authorized to program the device (24.8%) and wrong infusion rates set by anesthesia providers who were so authorized (24.8%). Conclusions: The findings provide valuable information that can aid in the development of policy and procedures for safer, more effective postoperative administration of IV PCA. They also suggest that it's necessary not only to improve the operation of acute pain services teams, but also to ensure ongoing provider and patient education specific to IV PCA use.

Using Video to Describe the Patient-Controlled Analgesia Pump Programming Process

“…Variation in syringe placement could be due to the lack of a clear and consistent message during PCA pump programming training 18 or inadequate training, 6 with the nurses not attending to all of the available information on the PCA pump. For example, we found that it took a while for 2 nurses to recognize that the morphine order was still displayed on the pump, although they had changed the syringe in the cassette to hydromorphone.…”

“…Two studies found that although the frequency of PCA pump errors was low (<1%), human error was the most common type. 5,6 Such findings suggest that ergonomic and cognitive engineering principles need to be incorporated into PCA pump design to reduce human error and improve safety. 6 At our institution, we use a type of medication infusion pump with an attachable PCA module.…”

“…5,6 Such findings suggest that ergonomic and cognitive engineering principles need to be incorporated into PCA pump design to reduce human error and improve safety. 6 At our institution, we use a type of medication infusion pump with an attachable PCA module. When connected to the basic infusion pump, the PCA module can deliver a continuous infusion of analgesic, deliver an analgesic only when the patient self-administers a dose by pressing a handheld button, or a combination of continuous and self-administered doses.…”

“…For example, Ohashi et al4 found that more than 89% of medications administered via PCA pumps had some type of error present and violations of hospital policy were common. Two studies found that although the frequency of PCA pump errors was low (<1%), human error was the most common type 5,6. Such findings suggest that ergonomic and cognitive engineering principles need to be incorporated into PCA pump design to reduce human error and improve safety 6…”

Evolution of Intravenous Medication Errors and Preventive Systemic Defenses in Hospital Settings—A Narrative Review of Recent Evidence

“…Our systematic search on Medline (Ovid) found 16 articles describing systemic causes of IV MEs published between June 2016 and October 2021 (Supplementary file 2, http://links.lww.com/ JPS/A612). These studies were conducted in the following 6 countries: United States (n = 6), 6,[30][31][32][33][34] United Kingdom (n = 5), [35][36][37][38][39] France (n = 2), 40,41 Canada (n = 1), 42 South Korea (n = 1), 43 and Spain (n = 1). 44 Most of the studies were carried out in a hospital setting without a specification of a specialty area (n = 7), 6,30,31,34,36,37,43 whereas some were conducted in a pediatric hospital setting (n = 3), 35,39,41 hospital pharmacy (n = 2), 32,42 emergency department (n = 1), 33 intensive care unit (ICU) and hematology sterile unit (n = 1), 40 neonatal intensive care unit (NICU) (n = 1), 44 and a simulated pediatric medical facility (n = 1).…”