R E V I E W S & A N A LY S E S Making Patient-Controlled Analgesia Safer for Patients H.T.M. Ritter III, BA, CBET, CCE Patient-controlled analgesic (PCA) infusion pumps allow patients to self-administer opi- Senior Patient Safety Analyst oid analgesics within the limits prescribed by a physician or other licensed professional. Pennsylvania Patient Safety Authority PCA therapy is used for postoperative, obstetric, terminally ill, and trauma patients. PCA pumps deliver solutions intravenously, subcutaneously, or epidurally and allow patient activation by means of a pendant button on a cord connected to the pump or a button directly on the pump. Accidental overdoses by patients are prevented by lockout ABSTRACT features on the pump and by the fact that heavily sedated patients will be too somno- The Pennsylvania Patient Safety Author- lent to self-administer more analgesics. ity has received approximately 4,500 The programmable features of pumps allow the clinician to select the drug concentra- event reports associated with patient- tion, patient bolus dose, lockout interval between patient-controlled boluses, and controlled analgesic (PCA) pumps (June a continuous (basal) rate. Drug concentration is typically specified in mg/mL, the 2004 through May 2010). PCA infusion patient-activated bolus dose is specified in mg, and lockout intervals between patient pumps allow patients to self-administer boluses are programmed in minutes. If a continuous rate is ordered, it would be in doses of pain-relieving medication as mg/hr or mcg/hr. needed, rather than having to sum- PCA pumps come in two main styles: larger pole-mounted pumps and smaller mon a caregiver. The most significant ambulatory-style pumps. Pole-mounted pumps are intended for bedside use, often in risk when using these pumps is over- an inpatient setting; most offer limited ambulation time. They emphasize function medication leading to opioid-induced for complex care, with larger display screens and easy-to-navigate menus that guide respiratory depression. This article the clinician through the programming process. These pumps generally offer more assesses this and other risks associ- computing power and therefore more comprehensive features, functions, and event ated with PCA therapy reported to the logs, and typically can only deliver medications that are available in prefilled vials or Authority. It reviews ways to prevent syringes. Ambulatory-style pumps are intended to be carried by the patient to allow adverse events. (Pa Patient Saf Advis ambulation in inpatient, outpatient, and home care settings; they may also be clamped 2011 Sep;8[3]:94-9.) to an intravenous (IV) pole. They typically deliver fluid from small bags or cassettes and emphasize portability and simplicity of programming. A dose error reduction system (DERS) is a critical element in detecting and preventing errors in prescribing and programming. Devices with this functionality are commonly referred to as “smart” pumps because they can compare programmed parameters (e.g., dose, concentration) against preset limits stored in a drug library; the limits are spe- cific to each drug and clinical location. If a clinician tries to program a dose outside the limits, the device alerts the clinician and either requires the program to be changed to something within the limits (these are referred to as “hard” limits) or allows the clinician to continue with the programmed infusion after acknowledging the alert (“soft” limits). OVERVIEW OF PCA INFUSION ERRORS The first six years of Pennsylvania Patient Safety Authority data (June 2004 through May 2010) contain approximately 4,500 reports associated with a PCA pump. (In the initial search, “PCA” was used for patient care assistant in approximately 20% of the reports.) Many of the reports related to patient-controlled analgesia reflected confusion about the infusion order but did not identify a source of error. Other reports docu- mented problems common to any infusion therapy: infiltration, tubing disconnection, medication leakage, and delay in therapy when a pump was unavailable. Delivering the wrong medication or the wrong amount are also reported for all infusion pumps, but the use of PCA pumps entails more hazards than use of other types of pumps. PCA pumps are used with potent opioids, so even small errors can lead to serious patient harm. For example, although it is counterintuitive, an erroneously programmed low drug concentration will cause a pump to deliver an excessive amount of the drug, caus- ing an overdose.1 Or, the concentration could be programmed as ordered but a vial or bag with a higher concentration could be selected and connected to the pump. Page 94 Pennsylvania Patient Safety Advisory Vol. 8, No. 3—September 2011 ©2011 Pennsylvania Patient Safety Authority The U.S. Food and Drug Administra- misinterpreting orders, pump mispro- concentration. The settings for the tion’s (FDA) Manufacturer and User gramming (e.g., concentration, bolus PCA were ordered in ml—1 ml/6 min/ Device Experience (MAUDE) database dose, lock-out interval), and running the 0 basal/10 ml hourly limit—but the reveals that reports of PCA-related device wrong drug or concentration: pump was set in mg—1 mg/6 min/ events are three times as likely to result PCA was ordered for morphine 1 mg 0 basal/10 mg hourly limit. The in injury or death as reports of device dose, 8 minute lock-out with 10 mg patient was a little sleepy but easily events involving general-purpose infusion hourly limit. PCA morphine concen- arousable, with an O2 saturation pumps. Authority analysts searched for tration comes as 1 mg/ml standard. of 95% and adequate respirations. all reports in the MAUDE database (as of PCA [pump] was programed as mor- Upon questioning, the RN caring January 31, 2011) for devices by both FDA phine 1 mg dose, 8 minute lock-out for the patient stated that the prior product code and outcome (i.e., outcome with 10 mg hourly limit with a PCA pump was malfunctioning. She = death or injury). Of 4,230 reports for 0.25 mg/ml concentration. At the got another PCA pump and repro- product code MEA (PCA pumps), 826 set concentration, the PCA [pump] grammed it but did not have another (19.5%) resulted in injury or death. Of delivered 4 ml for 1 mg dose when RN verify that she did reprogram the 48,961 reports for product code FRN it should have delivered 1 ml for replacement pump properly. (general-purpose pumps), 3,240 (6.6%) 1 mg dose, therefore giving 4 times Authority reports also illustrate several resulted in injury or death. This may be the ordered dosage each time. reasons why physiologic monitoring may due to the exclusive use of high-risk anal- be desirable during PCA. Respiratory gesics in PCA pumps. I went to verify orders for this patient and noticed that the patient’s depression is likely to occur when one Opioids commonly used in PCA therapy, HYDROmorphone PCA, patient or more medications (e.g., other central such as morphine, HYDROmorphone, administered dose, was increased from nervous system depressants or other opi- and fentaNYL, are considered to be high- 0.25 mg to 2.5 mg. I called the nurse oids by other routes of administration) alert medications.2 Approximately one to check if she knew the rationale are intentionally or inadvertently given to of four events reported to the Authority for such a large dosage increase. She a patient who is also receiving an opioid involved high-alert medications. Of those thought this seemed inappropriate and via a PCA pump. Reports also reveal pro- reports, 44% involved pain manage- spoke with the physicians who were gramming errors that were not detected ment medications often used for PCA, rounding at the time. The physician despite a double check by another nurse including morphine, HYDROmorphone, had intended to order 0.25 mg rather or during two shifts. Two reports illustrate meperidine, and fentaNYL.3 In addition, than 2.5 mg. The order was corrected. how monitoring helped alert clinicians in Authority data indicates that 21% of time to resuscitate patients with naloxone. look-alike name errors involved opioids Patient received from the PACU [postanesthesia care unit]. PCA A code was called for patient who and included name confusion among was not breathing. Patient was found morphine, HYDROmorphone (Dilaudid), documented as started by this RN [registered nurse]. Upon receiving the being assisted with her respirations and meperidine (Demerol).4 with bag-valve-mask ventilation by patient, the PCA was set as a 5 ml During a recent six-month period dose [0.2 mg/mL HYDROmorphone] respiratory therapy techs. She was (December 2009 through May 2010), with 10 minute lockout time; how- unresponsive and not breathing approximately 70% of the PCA therapy ever, it was ordered as 1 ml dose with adequately. She was given large related reports to the Authority were 5 minute lockout. Nurse practitioner amounts of sedation throughout the attributable to errors associated with was notified. day. From 0800 to 1600, the patient pump use (e.g., misprogrammed doses had received 200 mcg IV fentaNYL and concentrations, installation of the PCA was discontinued and it was via PCA pump; she also received, wrong drug or concentration). Naloxone found to have incorrect medication at 1200, 30 mg of po oxycodone SR (Narcan) was administered to reverse an given. The patient was ordered (sustained release). Then at 1700 she opioid overload in more than 10% of HYDROmorphone PCA, but mor- received 5 mg Dilaudid IV push. At these reports. Misprogramming of the phine was infusing. The pharmacy 1800, a code was called for respira- PCA pump is by far the most frequently was notified. tory arrest, and the patient required reported practice-related issue surround- We discovered the incorrect PCA transfer to ICU after for monitoring. ing PCA therapy.5 The following examples settings during rounds. The HYDRO- She had been reversed and recovered from Authority reports illustrate some of morphone syringe was the correct with the use of IV Narcan. the ways PCA errors may occur, including Vol. 8, No. 3—September 2011 Pennsylvania Patient Safety Advisory Page 95 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S A patient was admitted after an Alarm sounded, O2 saturation low; for individuals with renal impairment, automobile accident. The patient staff rechecked patient and found her have also been made. Occasionally, one went to OR. An order for Dilaudid unarouseable; respiratory code called. opioid has been prescribed, but the dose 1 mg IV every 4 hours as needed for PCA was stopped; Narcan was given has been for a different opioid.6 pain and oxycodone 12 mg PO BID twice with return to 97% saturation. Even with correct PCA orders, clinicians x 6 doses was made at 1700 post- Patient on PCA post total knee have been known to miscommunicate operatively. The patient was agitated arthroplasty. Noted to have snoring orders, sometimes leading to serious and had pinpoint pupils. An order to respirations, low pulse oximetry, som- errors. Concurrent orders for other opi- d/c [discontinue] the PCA was made nolent. Given Narcan 0.2 mg IVP, oids while PCA is in use have resulted at 1900 and it was to be started the more alert, responds to questions, in opioid toxicity. Problems also have next am. At 2000, Narcan 0.5 mg pulse ox returned to 97%. occurred when patients are started on IV was to be given and repeated as PCA therapy but have a documented needed to reverse narcotic effects as allergy to the ordered medication. One per order written in the chart. After FACTORS THAT CONTRIBUTE TO example includes an order that was given Narcan was given, the patient was ERRORS WITH PCA THERAPY for a “stat” dose of morphine, but the much more oriented and alert. patient had a documented allergy to this Improper Patient Selection Patient is on a PCA and I also gave drug. Fortunately, a pharmacist caught An important safety feature with demand Percocet in the morning for pain. No the error and contacted the physician, but PCA (PCA therapy without a basal rate) other narcotics should have been given not before the nurse used the override is that the patient delivers each dose. with the morphine PCA. function to remove morphine from the For this reason, candidates for PCA Dilaudid PCA programmed incor- automated dispensing cabinet and admin- should have the mental alertness and rectly by RN: drug concentration istered the drug to the patient.6 cognitive ability to manage their pain entered as 0.1 mg/ml instead of the and communicate their pain level to Errors have occurred even with the use actual 1 mg/ml. As a result of this their caregiver. However, the benefits of of facility-defined PCA order forms. In error, the patient received more drug PCA have led some healthcare providers one case reported to the Institute for Safe than intended over an 8-hour period to extend its use to less-than-ideal can- Medication Practices (ISMP), a 70-year- before the error was detected. This didates (e.g., young children, confused old patient received a tenfold overdose error was not detected as part of the elderly patients). Oversedation also has of HYDROmorphone. A physician pre- double-checks performed at initial occurred in less-than-ideal candidates scribed PCA using HYDROmorphone pump setup or change of shift. Patient who are at risk for respiratory depression 2 mg in 250 mL of normal saline became symptomatic and required because of comorbid conditions such as 0.9% injection, creating a concentration Narcan and supplemental oxygen. obesity, asthma, or sleep apnea or use of 8 mcg/mL. While writing the order on The patient did not require transfer to of concurrent drugs that potentiate opi- a preprinted form, he mistakenly entered a higher level of care. oids. However, even when these factors the 8 mcg/mL concentration on the The patient had a PCA morphine are identified and considered, patients wrong line. He quickly recognized the infusing, 0.2 mg patient bolus was respond to opioids in different ways, and mistake, scribbled over the erroneous ordered and 2 mg patient bolus was what is a safe dose for most patients can entry, and wrote the correct value of 2 mg being infused. Pharmacy was called cause dangerous reactions in a small per- in 250 mL. He then initialed and circled to double check concentration and centage of the population.6 the change.6 (See Figure.) physician assistant was notified of The pharmacist misinterpreted the circled error. Error went through two Prescription Errors initials as a zero and dispensed 20 mg shift changes. The PCA order itself can be a source of of HYDROmorphone in 250 mL normal [A patient with a] known history of error. Prescribers have made mistakes in saline, yielding a concentration of sleep apnea on PCA morphine devel- converting oral opioid doses to the IV 80 mcg/mL. The bag was labeled as oped respiratory arrest. [The patient route; most problematic is HYDROmor- “20 mg/250 mL NS,” but the concen- was] initially on 2 mcg basal, up to phone, which has an oral to IV conversion tration on the order was entered as 2.5 mcg when unable to achieve pain range of 3:1 to 5:1.7 Errors in selecting “8 mcg/mL.” Before administration, two control. The patient was then sleep- an opioid that is not appropriate for the nurses checked the bag using the original ing, and was easy to arouse for 6 hours. patient, such as prescribing meperidine order, but they only verified the labeled Page 96 Pennsylvania Patient Safety Advisory Vol. 8, No. 3—September 2011 ©2011 Pennsylvania Patient Safety Authority Figure. Patient-Controlled Analgesic Order RISK REDUCTION STRATEGIES Reducing Error through Standardized Protocols One way to minimize adverse events and medication errors with opioid PCA is through the use of standardized protocols.1 Some facilities have adopted Circled orders on patient-controlled analgesic order caused 2 mg to be interpreted facility-wide protocols for programming as 20 mg, which is a concentration that is 10 times greater than intended. PCA pumps. The protocols may include Reprinted with permission from the Institute for Safe Medication Practices, Horsham, Pennsylvania. standardized drugs, concentrations, and dosing regimens for typical patient characteristics—for example, protocols concentration, and the error was not available in prefilled syringes in concentra- labeled “Morphine Post-Op” for standard noticed because the concentrations on the tions of 1 mg/mL, 2 mg/mL, and 4 mg/mL. postoperative pain control or “Morphine, order form and on the mislabeled bag were As the estimated relative potency of IV Opioid-Tolerant” for patients who require the same. Later, the night nurse found the HYDROmorphone to morphine is 7.5:1, higher doses of drug to achieve adequate error while checking the bag against the these mix-ups can easily be fatal.7 pain relief. Dosing protocols are imple- original entire order.6 Patient harm has occurred with mix-ups mented in the form of either a preprinted between other pairs of opioids. In one order sheet or a preset list in an order Drug Product Mix-Ups report to ISMP, a pharmacist drew 50 mg entry system. Some opioids used for PCA have similar of 10 mg/mL HYDROmorphone from Using standardized protocols reduces names and packaging, which has led to a 5 mL ampule to prepare two epidural medication errors by limiting the number drug selection errors. Errors have occurred PCA orders for 500 mcg of 50 mcg/mL of choices a physician needs to make when prefilled vials of meperidine and fentaNYL. As a result, two women re- when prescribing (e.g., deciding between morphine have been packaged in similar- ceived opioid overdoses while in labor, a 1 mg bolus with 5-minute lockout and looking boxes. Morphine is available in and they and their babies developed respi- a 2 mg bolus with 10-minute lockout) prefilled vials in two concentrations, but ratory difficulties.6 and by reducing transcription and pro- the packaging may not allow quick differ- gramming errors related to hard-to-read entiation of the strengths.6 PCA by Proxy orders. Hospitals can also use dosing Pharmacy-applied labels may look similar Patients may be harmed even if the pump’s protocols to standardize on one or a few on extemporaneously prepared syringes programming matches the medication concentrations of each drug, reducing the or bags. Since opioids are typically in unit order. The effects of opioids may be diffi- likelihood of medication errors due to stock, when a new order is written, the cult for caregivers to anticipate: a dose that selecting the wrong-drug concentration nurse sees the order and takes the medi- is sufficient for one patient may oversedate when obtaining a drug vial or entering cation out of the automated dispensing another. Reports also indicate that PCA the concentration into the pump. Many cabinet, frequently with no independent pump patients have received dangerous of the risk reduction strategies presented double check. These errors are rarely and even lethal amounts of opioids when in the September 2010 Pennsylvania Patient detected and can lead to significant family members or clinicians activated the Safety Advisory article “Adverse Events with overdoses.6 pump’s delivery request button on the HYDROmorphone: How Preventable Are patient’s behalf (i.e., PCA by proxy). They?” are also applicable.7 Name similarities also have led to inad- vertent mix-ups between morphine and It is essential, therefore, that clinicians be aware that allowing anyone other than Monitoring during PCA HYDROmorphone or the mistaken belief that HYDROmorphone is the generic the patient to press the delivery request The primary concern with opioid overse- name for morphine. Thirty-two percent button is a clear contraindication of PCA dation is respiratory depression and even of the opioid look-alike-name events therapy and has been strongly warned respiratory arrest. The usual approach to reported to the Authority have involved against by the Authority, ECRI Institute, minimizing this risk is to have nursing these two drugs. Contributing factors ISMP, and the Joint Commission.5,8-10 periodically assess patients on PCA. In include the fact that both drugs are addition, pain scores are crucial, because Vol. 8, No. 3—September 2011 Pennsylvania Patient Safety Advisory Page 97 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S pain is recognized as the “fifth vital sign” PCA—in particular those with obstructive error, especially before administering and is the therapeutic monitoring param- sleep apnea—in the short-term. a bolus dose. In particular, inde- eter to determine dose adjustments (either At an October 2010 infusion device pendently double-check the drug, increase or decrease). ISMP has noted summit cosponsored by the Association concentration, pump setting, and that the common practice of assessing for the Advancement of Medical Instru- line attachment.6 the patient while interacting with him or mentation and FDA, the Veterans Health 9. Ensure that oxygen and naloxone are her is inadequate since an overly sedated Administration stated that PCA pumps readily available where opioids are patient can be aroused and respond to with an integrated end tidal carbon dioxide administered.2 questions but will fall back into overseda- monitor could have prevented 60% of 10. Educate patients about the proper tion when the nurse leaves. Accordingly, adverse events identified in 69 root cause use of PCA (e.g., during a preopera- ISMP recommends observing the patient analyses related to PCA pumps.15 In addi- tive testing visit) before initiation unobtrusively and noting both respira- tion to alarming, an integrated monitor when patients are not too groggy tory rate and depth of respiration in the would halt further opioid delivery by to understand.6 absence of any stimulus.11 deactivating the pump. 11. Warn family members and visitors Continuous monitoring is another tool about the danger of PCA by proxy.6 to reduce the risk of oversedation. Pulse Special Precautions oximetry is ubiquitous, easy to use, and 12. When possible, continuously moni- Healthcare facilities may consider relatively inexpensive. A recent study tor patients at risk for respiratory implementing special precautions when using continuous pulse oximetry monitor- depression (e.g., patients with comor- administering opioids to patients with ing in an orthopedic unit (where patients bid conditions or who are receiving PCA pumps, including the following: frequently receive PCA therapy and are concurrent drugs that potentiate not typically connected to physiologic 1. Limit choices by minimizing the opioids).13,14 monitoring) concluded that it resulted in variety of medications and concen- reduced need for rescues and intensive trations used for PCA.6 CONCLUSION care unit transfers.12 Pulse oximetry is also 2. Restrict fentaNYL PCA admin- PCA therapy is an effective way to provide recommended for selected patients receiv- istration to anesthesia or pain pain management. However, reports to ing epidural or spinal opioids.13 management team members only. 6 the Authority illustrate the multiple ways However, while useful, pulse oximetry 3. When available use “smart” PCA that errors with PCA happen frequently, does not measure ventilation. Since pumps that can alert clinicians to sometimes with tragic consequences. oxygen saturation is a lagging indicator potential programming errors.6 Although smart infusion pumps can help of respiration, pulse oximetry may not 4. It is desirable to match the sequence detect medication errors, and patient indicate a problem early enough for of information that appears on PCA monitoring can detect the results of errors, effective intervention. Pulse oximetry is medication labels and order sets with clinicians should nevertheless question even more problematic for patients who the sequence of information that must orders for drugs or doses that are illegible are receiving supplemental oxygen, since be entered into the PCA pump. 6 or appear unsafe, ensure that the correct they may be adequately oxygenated even 5. Drug names are less likely to be concentration has been selected, request with dangerously depressed ventilation. confused if tall man lettering is used independent double checks of pump Capnography, or end-tidal carbon dioxide (e.g., HYDROmorphone).5 programming, use proper patient identifi- monitoring, allows clinicians to track sev- 6. Patients must be cognitively, physi- cation techniques, and periodically assess eral indicators, but for purposes of PCA cally, and psychologically capable of patient vital signs and level of sedation. it is primarily used as a reliable monitor understanding the concepts of PCA.10 Error-reduction strategies for PCA therapy for respiratory rate, including apneic 7. Clearly define a manual independent should include a balanced approach of episodes. The Anesthesia Patient Safety double-check process for clinicians practice-related, system-related, product- Foundation (APSF) advocates monitoring to follow when verifying PCA related, and device-related efforts. By both oxygenation and ventilation in all medications, pump settings via a embracing proven prevention strategies, patients receiving PCA.14 However, APSF confirmation screen, the patient, and healthcare facilities can help reduce the also recognizes that universal monitoring line attachments.6 risks associated with this technology and will not be implemented immediately improve patient safety. 8. If a patient is not responding to PCA and therefore suggests using available doses, consider the possibility of an monitors for the highest risk patients on Page 98 Pennsylvania Patient Safety Advisory Vol. 8, No. 3—September 2011 ©2011 Pennsylvania Patient Safety Authority NOTES 1. ECRI Institute. Medication safety: PCA 2007 [online]. Available from Internet: 11. Cohen MR. Safety issues associated pump programming errors continue to http://www.ismp.org/profdevelopment/ with patient-controlled analgesia. In cause fatal overinfusions [hazard report]. PCADrugLibrariesforwebce.pdf. Patient-controlled analgesia: making it safer Health Devices 2002 Sep;31(9);342-6. 7. Adverse events with HYDROmorphone: for patients. Institute for Safe Medication 2. Institute for Safe Medication Practice. how preventable are they? Pa Patient Practices; 2006 [online]. Available High-alert medication feature: reducing Saf Advis [online] 2010 Sep [cited 2011 from Internet: http://www.ismp.org/ patient harm from opioids. ISMP Med Saf Jan 31]. Available from Internet: http:// profdevelopment/PCAMonograph.pdf. Alert, 2007 Feb 22;12(4):2-3. patientsafetyauthority.org/ADVISORIES/ 12. Taenzer AH, Pyke BE, McGrath SP, et 3. Focus on high-alert medications [online]. AdvisoryLibrary/2010/Sep7(3)/Pages/ al. Impact of pulse oximetry surveillance PA PSRS Patient Saf Advis 2004 Sep 69.aspx. on rescue events and intensive care unit [cited 2011 Jan 31]. Available from 8. PCA by proxy—an overdose of care transfers: a before-and-after concurrence Internet: http://patientsafetyauthority. [online]. PA PSRS Patient Saf Advis study. Anesthesiology 2010 Feb;112(2):282-7. org/ADVISORIES/AdvisoryLibrary/ 2005 Jun [cited 2011 Jan 31]. Available 13. American Society of Anesthesiologists 2004/Sep1(3)/Pages/06.aspx. from Internet: http://www.patient- Task Force on Neuraxial Opioids. 4. Medication errors linked to drug name safetyauthority.org/ADVISORIES/ Practice Guidelines for the prevention, confusion [online]. PA PSRS Patient Saf AdvisoryLibrary/2005/jun2(2)/Pages/ detection, and management of respiratory Advis 2004 Dec. Available from Internet: 23.aspx. depression associated with neuraxial http://patientsafetyauthority.org/ opioid administration. Anesthesiology 2009 9. ECRI Institute. Triggering patient- Feb;110(2):1-13. ADVISORIES/AdvisoryLibrary/2004/ controlled analgesic pumps by clinicians dec1(4)/Pages/07.aspx. or visitors could be lethal [hazard report]. 14. Stoelting RK, Weinger MB. Dangers of 5. Institute for Safe Medication Practice. Health Devices 2004 Jan;33(1):24-5. postoperative opioids—is there a cure? Safety issues with patient-controlled [editorial]. APSF Newsletter Summer 10. Joint Commission. Patient-controlled 2009;24(2):25. analgesia. Part I—how errors occur. ISMP analgesia by proxy [online]. Sentinel Med Saf Alert, 2003 Jul 10;8(14):1. 15. Association for the Advancement Event Alert 2004 Dec 20 [cited 2011 6. Grissinger M. Overview of PCA of Medical Instrumentation. Lead- Jan 31]. Available from Internet: infusion errors. In: PCA drug libraries: user profile: the Veterans Health http://www.jointcommission.org/ designing, implementing, and analyzing Administration; root cause analysis shapes sentinel_event_alert_issue_33_patient_ CQI reports to optimize patient safety. safety initiatives. In: Infusing patients controlled_analgesia_by_proxy. Institute for Safe Medication Practices; safely: priority issues from the AAMI/ FDA infusion device summit. 2010:12. Vol. 8, No. 3—September 2011 Pennsylvania Patient Safety Advisory Page 99 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 3—September 2011. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2011 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR Reader to subscribe to receive the Advisory for free.