Patient-Controlled Analgesic Pumps May Cause Medication Errors in Hospital Patients

Any hospital patient who has counted the minutes until her next dose of pain medication can tell you how agonizing that wait can be. Hospital staff accept that medication is “on time” so long as it is administered 30 minutes before or after the scheduled time for the next dose. If a nurse is dealing with an emergency or another patient, the time between doses could potentially be extended. For these reasons, some hospitals employ the use of patient-controlled analgesic pumps (PCAs). These machines allow patients to self-administer pain medication as needed based on their prescriptions.

The Morning Call reports that after three patients at a Pennsylvania hospital were injured due to drug overdoses associated with patient controlled pumps, the Pennsylvania Patient Safety Authority investigated the use of PCAs. Investigators found that between 2004 and 2010, 4,230 problems were reported and 20 percent of those experiencing issues were injured or killed. These problems were typically medicine errors where the wrong amount was programmed into the PCA, allowing the patient to overdose.

In an effort to reduce the risk of overdose, some hospitals have begun using smart pumps. These models include an alarm that will sound if a programmed dose exceeds pre-set limits, reducing the risk of a pharmacist, doctor, or nurse making a miscalculation leading to a patient getting the wrong dose. Hospitals typically verify the medication dosage independently in addition to relying on the PCA in order to prevent hospital drug mistakes.

Manufacturers are working to improve patient-controlled pump technology to further reduce the risk of accidental overdose. But PCAs are subject to other problems as well. In some cases, patients using the pumps are poor candidate for the systems. Those who are underage, overweight, confused, or on other medications should not use the pumps. Doctors and nurses must also ensure patients are not given the wrong medicine. For example, in some PCA cases, morphine and hydromorphone are mixed up. Hospitals must continue to put policies and procedures in place to safeguard all medication errors.


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