By Michael Wong

(This article has also been published in SurgiStrategies, which can be read here.)

According to its newly-updated, “How-to Guide: Prevent Harm from High-Alert Medication”, the Institute for Healthcare Improvement (IHI) looked at high-alert medications, which are “more likely than other medications to be associated with harm”.

One of the areas that the IHI singles out is narcotics. The IHI guide points out the necessity and importance of narcotics in treatment:

Pain management is an important component of patient care. Implementing appropriate pain management protocols not only ensures that patients receive pain relief, but also minimizes opportunities for errors and harm. Effective pain control is integral to good health and to recovery from injury, surgery, and illness.

However, with this benefit may come the potential for harm. As the guide finds:

A review of costs associated with errors related to patient-controlled analgesia (PCA) and device related narcotic errors found that each error cost $552 – $733; harmful errors were 120 – 250 times more costly than those without harm. The authors estimated an annual rate of 407 PCA related and 17 device-related errors per 10,000 people in the United States.

However, adverse events with PCA pumps may occur even without an error being committed by attending healthcare professionals. As Frank Federico, RPh (Executive Director at IHI) points out, “Many patients may experience harm even with appropriate dosing of narcotics. This is a critical point for patients, their families and their caregivers to know — a patient may experience respiratory depression, leading to death, even if the PCA pump has been programmed correctly. Many believe that some of the adverse effects are the cost of doing business.  Our goal should be to reduce all harm, understanding that we may not know how to today. When a patient dies from respiratory depression, the toll on the patient’s family, friends, and community are enormous. The cost of adverse events goes beyond the costs associated with a medical malpractice claim.”

In their study, “Programming errors contribute to death from patient-controlled analgesia: case report and estimate of probability,” researchers determined that mortality from programming errors with PCA pumps was estimated to be a low-likelihood event (ranging from 1 in 33,000 to 1 in 338,800), but relatively high in absolute terms (ranging from 65 to 667 deaths). In other words, when harm from PCA occurs, it is likely to result in death.

Moreover, when PCA pump events were correlated against costs, quite understandably, non-harmful events were estimated to cost about $28 per event, but a harmful adverse event determined to be opioid related was $13,803 per event, as this study, “The Rate and Costs Attributable to Intravenous Patient-Controlled Analgesia Errors” showed:

As Rodney Hicks , PhD, APRN, FAANP, FAAN (Professor, Western University College of Graduate Nursing, Pomona, California), says, “Our study highlighted that IV PCA has a higher likelihood of errors, because of the complexity of IV PCA administration. Practitioners should capitalize on capnography and future innovations, such as linking monitoring alarms to the hospital’s network, to alert staff when a patient may be experiencing respiratory depression. Using such technology will realize potential cost savings or avert future costs associated with adverse events with PCA pump.”

Steps taken by Veterans Health Administration to avert PCA events echo these sentiments. As Bryanne Patail, biomedical engineer at the U.S. Department of Veterans Affairs, National Center for Patient Safety describes how VHA implemented a “strong fix” to reduce PCA-related events by more than 60%:

Use of PCA pumps is a process, and improving that process is an area that involves many stakeholders. 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.

Moreover, I asked David Watson (VP at ECRI Institute) whether ECRI concurs with VHA’s recommendations. ECRI is an independent, nonprofit organization that researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care.

Watson replied to me:

Infusion devices regularly appear within our Top 10 Technology Hazards list.  We cited PCA pumps within that list back in November 2010 in relation to the risks of oversedation and the associated potential for narcotic induced respiratory depression.  Infusion systems should be viewed as one component of a medication delivery system.  Other components within the process may include the need to ensure adequate monitoring is in situ.  In relation to this ECRI Institute is aware of previous studies suggesting that the concurrent use of pulse oximetry and capnography can lead to the early identification of respiratory depression. 

We have previously recommended the development of an action plan to implement effective physiological monitoring of patients on PCA therapy.  As such, I would concur with the VHA recommendations on this.

In short, we currently have the technology to catch and prevent many adverse events with PCA pumps. As Dr. Robert Stoelting (President, Anesthesia Patient Safety Foundation) explains:

Future technology developments may improve the ability to more effectively utilize continuous electronic monitoring of oxygenation and ventilation in the postoperative period.  However, maintaining the status quo while awaiting newer technology is not acceptable” [Dr. Stoelting’s emphasis].

• Opioid Safety
• Respiratory Compromise