More than 56,000 adverse events and 700 patient deaths were linked to patient-controlled analgesia (PCA) pumps in reports to the Food and Drug Administration between 2005 and 2009. In fact, 1 out of 378 post-surgical patients are harmed or die from errors related to PCA pumps.
To help prevent such errors in the future, the Physician-Patient Alliance for Health & Safety (PPAHS) has released a downloadable tool aimed toward enhancing PCA pump safety, based on data collected from clinical professionals. The PPAHS checklist tool concentrates its efforts on the top three risks uncovered in the data: that a patient can potentially receive too much medication; that injury and death can occur even if there are no errors with the pump; and that oximetry monitoring may not be sufficient.
The PCA Safety Checklist is meant to remind caregivers of the essential steps to take to initiate and assess use of PCA pumps. However, it’s not meant to be a comprehensive guideline. With that in mind, let’s take a closer look at the checklist and its advice for minimizing adverse events.
Step by step
These are the 6 key tasks any time PCA pump use is initiated, a pump is refilled or there’s a change in pump programming (these steps were recently published in the February 2013 edition of Outpatient Surgery or click 6 Steps to Prevent PCA Errors – OP Surgery 2013 to view pages 102-103).
1. Assess for risk factors that increase the risk of respiratory depression, in order to gauge risk and adjust medication dose accordingly. These factors include obesity and low body weight; concomitant medications (opiates and nonopiates alike) that potentiate the sedative effect of opiate PCA; pre-existing conditions such as asthma, chronic obstructive pulmonary disease and sleep apnea; and advanced age.
2. Perform a pre-procedural cognitive assessment to determine whether the patient is capable of participating in pain management. For example, elderly patients with symptoms of dementia or pediatric patients may not be suitable candidates for PCA pump use.
3. Educate the patient and provide him with information on proper use of the PCA pump and how to check it for issues. It’s also a good idea to provide the patient’s caretaker(s) with the same information.
4. Double-check key information. Two healthcare providers (usually the anesthesiologist and a PACU nurse) should independently review, verify and confirm the following: patient ID; all patient allergies appearing on the medication administration record; the drug selection and concentration as prescribed; the completion of any necessary dose adjustments; the PCA pump’s settings; and the integrity of the line attachment to patient and tubing insertion into the pump. Empower all providers to speak up if they spot an issue or inconsistency.
5. In your facility, monitor the patient with both pulse oximetry and capnography.
6. Assess and document the patient’s condition before discharge to home after surgery.
Power of the checklist
The PCA Safety Checklist is the latest among a number of medical checklists, all looking to improve processes and thereby reduce medical errors. Brigette Hales, the manager of patient safety and performance improvement at Sunnybrook Health Sciences Centre in Toronto, Ontario, and colleagues reviewed more than 1,000 abstracts on medical checklists in their paper, Development of Medical Checklists for Improved Quality of Patient Care.
“Checklists have been shown to play a fundamental role in error management,” explains Ms. Hales, “High-intensity fields of work, such as the airline industry and the military, already employ checklists to decrease errors of omission, improper implementation of procedures and protocols, and to decrease human error under stressful conditions.”
Moreover, checklists should be seen as a considered set of protocols. They are not a substitute for good care. Rather, they are an aid to better care.
“The value of medical checklists lies in their concise consolidation of a considered body of knowledge in one simple document,” says Eric Coleman, MD, professor of geriatric medicine and director of the care transitions program at the University of Colorado in Denver, who developed the physician checklist to reduce readmissions. “Their protocols should be considered and seen as an aid for clinicians to help increase patient safety and improve health outcomes.”