Accreditation

Latest Sentinel Event Alert focuses on PCA danger

Briefings on Accreditation and Quality, February 1, 2005

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Editor's note: This story is adapted from a fax express sent to BOJ subscribers December 20 after the JCAHO released Sentinel Event Issue #33.

Teach patients and their families how to use patient-controlled analgesia (PCA) properly, states the JCAHO's latest Sentinel Event Alert.

Serious errors can occur when someone other than the patient becomes involved in administering the pain medication, which is known as "PCA by proxy," the JCAHO said. According to two U.S. Pharmacopeia error-reporting databases, 15 of 460 harmful errors to patients between September 1998-December 2003 were the result of PCA by proxy.

Twelve of those errors were the result of a patient's family member administering PCA by proxy, according to the JCAHO. Two errors occurred because a nurse administered PCA by proxy, and the other was attributed to a pharmacist.

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