Capnography, Patient-Controlled Analgesics, PCA

PCA usage: a top health technology hazard for 2012

by Michael Wong

In its 2012 report on technology hazards, ECRI Institute lists as its number three hazard Medication Administration Errors Using Infusion Pumps (including, patient-controlled analgesia-PCA). The reason:

“Patients can be highly sensitive to the amount of medication or fluid they receive from infusion pumps; what’s more, some medications are life-sustaining. Therefore, infusion programming mistakes such as mistyping data or entering it into the wrong field can have severe adverse effects, including death. Infusion pump technology has evolved over the years to address many safety issues, the most notable improvement being the introduction of ‘smart’ pumps. But preventable errors, including misprogramming, do still occur.”

According to James P. Keller, Jr., ECRI Institute’s Vice President, Health Technology Evaluation and Safety, “With so many health technologies being used today, it can be difficult for hospitals to decide how to prioritize their safety efforts. Our list can be used as a guide to help hospitals focus on the most important issues.”

The point of the report is not to discourage the use of health technology. As ECRI notes at the top of its report, “Health technology offers countless benefits. It also presents numerous risks. Most of these can be avoided – with work.”

So, how can safety be improved and errors reduced regarding PCA pumps? Or, as ECRI puts it, what “work” needs to be done?

The ECRI report cites the FDA issued a white paper (FDA 2010 “Infusion Pump Improvement Initiative”). There the FDA, in its root cause analysis, discusses what can be done to improve safety:

Some 978 of the root cause analyses conducted [by the Veterans Health Administration] over 11 years involve medical devices. More than 13 percent of these, 129 in all, pertain to two types of infusion pumps—60 on general-purpose pumps and 69 on PCA pumps. Based on these root cause analyses, the VA’s integrated product team recommended that PCA pumps with an integrated end tidal CO2 monitor is the pump of choice, because use of this technology could have prevented more than 60 percent of adverse events related to PCA pumps.

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