APSF, Capnography, Monitoring Liability and Costs, Patient Safety, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring

Reducing Errors by More than 60 Percent: PPAHS Presents at the Northern Regional Respiratory Care Conference

by Sean Power

Last week, the Physician-Patient Alliance for Health & Safety presented two cases in which health care facilities reduced PCA-related adverse drug events with continuous electronic monitoring.

Experts estimate that anywhere from 600,000 to 2,000,000 PCA errors occur each year. As Dr. Richard Dutton, Executive Director of the Anesthesia Quality Institute, states, “PCA errors certainly occur, both in programming and in delivery, but any published estimate is likely to be only the tip of the iceberg.”

PCA errors certainly occur, both in programming and in delivery, but any published estimate is likely to be only the tip of the iceberg.” Dr Richard Dutton Executive Director Anesthesia Quality Institute

PCA errors certainly occur, both in programming and in delivery, but any published estimate is likely to be only the tip of the iceberg.”
Dr Richard Dutton
Executive Director
Anesthesia Quality Institute

Two hospital systems have implemented solutions to reduce the number of PCA errors.

The Veterans Health Affairs Solution: Implement Strong Fixes

The Physician-Patient Alliance discussed an interview conducting by our executive director Michael Wong with Bryanne Patail, Biomedical Engineer with the U.S. Department of Veterans Affairs, National Center for Patient Safety.

In that interview, Mr. Patail explained how fixing processes leads to better patient outcomes: “In looking at fixes, they can be categorized as strong, intermediate, or weak fixes. The strongest fix for PCA pumps is a forcing function, such as an integrated end tidal CO2 monitor that will pause the pump if a possible over infusion occurred. So, healthcare providers should first look at these strong fixes. There they will see the most impact on reducing errors and improving patient safety.”

Mr. Patail estimates that using capnography, which measures in real-time the adequacy of ventilation, could prevent more than 60 percent of adverse events related to PCA pumps.

The St. Joseph’s/Candler Hospitals Story: Entering Their 8th “Event Free” Year

The Physician-Patient Alliance also discussed how St. Joseph/Candler has been opioid adverse event free for more than 8 years.

St. Joseph’s/Candler’s Hospitals is the largest healthcare system in southeast Georgia with 675 beds and approximately 25,000 annual discharges. In less than a two-year period, they witnessed three significant adverse drug events. To address the problem, in 2002, SJCHS began to replace its existing traditional IV pumps with “smart” IV safety systems—PCA pumps with integrated capnography.

SJCHS estimates that at least 471 adverse drug events have been prevented in eight years since implementing capnography. Equally impressive, the hospital estimates it has prevented $4 million in expenses, not including potential litigation costs. This money can go toward other areas of patient care.

After five years, SJCHS saw $2.5 million return on investment. As Ray Maddox and Carolyn Williams reminds audiences in their paper, “Clinical Experience with Capnography Monitoring for PCA Patients” (APSF Newsletter Winter 2012), there can never exist an adequate monetary valuation of a life saved from preventing an adverse drug event.

Preventing PCA Errors at Your Hospital

The Physician-Patient Alliance, in collaboration with clinical professionals, developed a PCA Safety Checklist that reminds caregivers of the essential steps to take to initiate and assess the use of PCA pumps. While the PCA Safety Checklist is not a comprehensive guideline, the document summarizes evidence-based research that helps decision makers reach solutions.

The PCA Safety Checklist has received some praise by healthcare professionals:

Frank Federico, RPh (Patient Safety Advisory Group at The Joint Commission and Executive Director at the Institute for Healthcare Improvement):

Use and adherence with standardized processes for eligible patients leads to better clinical outcomes. The PPAHS PCA checklist lays out essential steps to be taken to initiate patient-controlled analgesia (PCA) with a patient and to continue to assess that patient’s use of PCA. Following these steps will help to increase patient safety and save lives.

“A checklist would help avoid many things that could go wrong with PCA.” –Dr. Elliot Krane, Director, Pediatric Pain Management, Lucile Packard Children’s Hospital at Stanford.

“A checklist would help to avoid simple but recurrent errors in packaging and programming the PCA.” –Dr. Richard Dutton, Executive Director, Anesthesia Quality Institute.

“In practice, checklists serve as a mental reminder of critical steps that we may or may not remember. Therefore, the value of a checklist with regards to PCAs would be to remind us/double check a critical step in the process.” –Dr. Julius Cuong Pham, Department of Emergency Medicine, Department of Anesthesia and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality at Johns Hopkins University School of Medicine.

“The use of a well-constructed checklist that ensures proper procedures are followed in patient-controlled analgesia would enhance patient safety.” –Dr. Andrew Kofke, Co-Director Hospital of the University of Pennsylvania Neurocritical Care Program.

You can download the free pdf version of PCA Safety Checklist here or a “checkable” and changeable word version of the PCA Safety Checklist by going to the top right hand corner of our website http://www.ppahs.org

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