The Center for the Advancement of Patient Safety issued an alert about a high rate of harmful errors associated with pain-medication pumps programmed to be used by patients at their discretion. The center, a unit of U.S. Pharmacopeia, Rockville, Md., found that the chance of patient harm from patient-controlled analgesia, or PCA, pumps was nearly four times the harm rate for all error reports in its Medmarx database. Medmarx has amassed nearly 500,000 error reports from 700 hospitals since its launch in 1998. Of 5,377 PCA-related records in Medmarx and a second database, dating from September 1998 through August 2003, 7.9% were categorized as harmful. By comparison, 2% of errors overall were tagged as harmful.
Errors occur although PCA pumps have safety features intended to prevent patients from giving themselves excessive amounts of narcotics and other strong painkillers, said Diane Cousins, the center's vice president. "These same features can introduce error into the process if healthcare professionals are not aware of or skilled in the use of these features," Cousins said. The center issued six recommendations to clinicians to prevent PCA errors, including use of bar codes on all patient-administered medications and educating families and hospital staff not to act for the patient in deciding whether to push the pump button. Read the center's report. -- by John Morrissey