JCAHO issues sentinel event alert on PCA pumps
Patient Safety Monitor Alert, December 22, 2004
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The JCAHO issued a sentinel event alert on patient controlled analgesia (PCA) by proxy on December 20, warning of the potential risks of the practice.
Serious adverse events can occur when an unauthorized family member, caregiver, or clinician administer PCA "by proxy," states the alert. It cites that 6,069 PCA errors were submitted to the United States Pharmacopeia (USP) medication errors databases. 460 of these errors were fatal or harmful to patients, and 15 of the 460 cases resulted from PCA error by proxy-someone other than the patient pushing the PCA button to administer medication.
The alert's recommendations include:
- developing a "criteria-based selection process" to determine which patients are appropriate to receive PCA
- monitoring PCA patients carefully
- educating patients and family members about the dangers of PCA by proxy
- making sure staff know that administering a PCA dose for a patient outside of a nurse-controlled analgesia protocol is dangerous
- considering posting tags and signs warning that only the patient should press the PCA button
To read the alert, click here.
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