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JCAHO offers five tips to reduce PCA errors in Sentinel Event Alert

Pharmacy Regulation Resource, December 22, 2004

The JCAHO on December 20 issued a Sentinel Event Alert warning hospitals about the dangers of people other than patients operating patient-controlled analgesia (PCA) devices.

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 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 of a nurse administering PCA by proxy, and one was attributed to a pharmacist.

The JCAHO offers five steps to curtail PCA errors. They include

• creating criteria for selecting patients who can receive PCA
• monitoring patients for suppressed breathing and heart rates
• educating patients and families about the proper use of PCA, including instructions to family members not to administer PCA
• telling staff about the dangers of giving a dose outside of the acceptable range
• placing warning signs on pumps or in areas where PCA is used, instructing only patients to press the PCA control button

For example, staff at Metropolitan Hospital in Grand Rapids, MI, created colorful, multilingual signs to attach to all PCA pumps, warning family members not to touch them, says Regina Ricketts, RN, the hospital's quality management coordinator.

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