• 21
    Feb
  • Safety and Patient-Controlled Analgesia: FLAWS IN DEVICE DESIGN

Safety

Multiple steps are required to program a PCA pump, but the pump’s design is often far from intuitive. Most programming errors have resulted because concentration settings for opiates such as morphine default to 0.1 mg/mL or 1 mg/ mL, but a higher concentration is available and is selected and mistakenly used. Other common design flaws that facilitate programming errors include:

  • pumps that do not require users to review all settings before the infusion starts
  • pumps that require users to program the dose in milliliters, not milligrams; this can cause operators to overlook the amount of drug the patient is actually receiving.

Some of the design flaws are related to the patient’s use of the pump. For instance, because the activation button looks like a nurse call bell, patients have inadvertently given themselves a dose of analgesic while believing they were pressing the button to call a nurse.
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With lockout intervals set, unless the pump provides visual or auditory feedback, patients cannot tell whether the press of the button has resulted in the actual delivery of medication. As a result, some patients press the button more frequently than they would had they received the proper feedback. Other patients become frustrated and give up; the result is pain that is undertreated.

INADEQUATE STAFF TRAINING

A number of steps are required to enter a PCA prescription into a pump. However, nurses do not always receive adequate training in programming pumps, and they do not always retain their proficiency after training if multiple pumps are in use or if they encounter a patient using PCA only infrequently.

In addition, prescribers do not always undergo a credentialing process designed to verify their proficiency with this form of pain management. Prescription errors, including improper drugs or doses, have resulted.

PRESCRIPTION ERRORS

The PCA order itself can be a source of errors. Physicians have made mistakes in converting an oral opiate dose to the IV route. Most problematic is hydromor-phone, which has an oral-to-IV conversion range of 3:1 to 5:1. Some physicians have prescribed a drug to which the patient is allergic, and they have selected an opiate that is not appropriate for the patient, such as prescribing meperidine for patients with renal impairment.

Occasionally, one opiate has been prescribed but the accompanying dose has been appropriate for a different opiate. buy antibiotics canada

Even with correct PCA orders, clinicians have been known to mishear or misread verbal or written orders, sometimes leading to serious errors. Concurrent orders for other opiates (oral or parenteral) while PCA is in use have also resulted in opiate toxicity.

In the January 2008 issue of P&T, the second part of this series will cover the strategies to reduce errors in PCA administration. These methods include a balanced approach of efforts related to the practice of administering PCA, the PCA system, the products used, the device itself, and regulations regarding the technique to be used. It is time that we work together to reduce the risks associated with this wonderful technology.

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