Pharmacy and Therapeutics - January 2008 - (Page 8) MEDICATION ERRORS Safety and Patient-Controlled Analgesia Part 2: How to Prevent Errors Matthew Grissinger, RPh, FASCP Mr. Grissinger is Director of Error Reporting Programs at the Institute for Safe Medication Practices in Huntingdon Valley, PA (ww.ismp.org). verify their proficiency with this form of pain management. Only anesthesia staff members, the pain-management team, or critical-care prescribers may order fentanyl for epidural PCA. Standard order sets should be designed to guide drug selection, doses, and lockout periods; patient monitoring; and precautions. Order sets should provide instructions on how and when to administer oxygen and naloxone. Concomitant analgesics should be avoided. The pump’s programming sequence should be used to test the sets in order to reduce the risk of errors. After receiving instruction, nurses should: ° be familiar with the opiates used for PCA. ° recognize the dangers of administering a dose for the patient (known as “PCA by proxy”). ° understand the differences between hydromorphone (e.g., Dilaudid, Abbott) and morphine. ° be able to identify the signs and symptoms of opiate toxicity and withdrawal. ° know when to assess patients showing a minimal response to verbal or tactile stimulation. ° know how to distinguish between oversedation and other pulmonary, neurological, or cardiovascular complications. Both nurses and pharmacists should be taught how to program PCA pumps; their ability to enter a PCA prescription accurately should be verified. Training should take place close to the time when new pumps are introduced, not months beforehand. Practice sessions should be offered as needed to maintain proficiency. Simulations should be run in which staff members intentionally write incomplete orders, select an inappropriate drug or dose, misprogram a pump, ignore double checks, forget critical monitoring points, and overlook obvious signs of toxicity so that clinicians can identify the behaviors that place patients at risk. Clinicians should be provided with ongoing education to increase their awareness about PCA errors. Personnel are encouraged to report PCA errors within their institution as well as to the Food and Drug Administration, the Institute for Safe Medication Practices, and the U.S. Pharmacopeia. Competency assessments should be required each year for all professionals who prescribe, dispense, and administer PCA. Criteria should be established for selecting patients who would be eligible to use PCA. PCA candidates should have an appropriate level of consciousness and a cognitive ability to self-manage pain. Infants, young children, and confused patients are unsuitable candidates for PCA. • • • P atient-controlled analgesia (PCA) has considerable potential to improve pain management. However, errors happen frequently, sometimes with tragic consequences. Part 1, “How Errors Occur,” was the topic of last month’s Medication Errors column. This month, Part 2 presents a checklist of efforts related to practice, systems, products, PCA pumps, and regulations that can help reduce the risks associated with this patient-centered technology. • • • • • • Purchasing a PCA Pump • The actual PCA pump to be evaluated should be subject to a failure mode-andeffects analysis. Here are some sample questions to consider: ° Can the pump be easily programmed to deliver the desired concentrations? ° Might unsafe administration accidentally allow free flow to occur? ° Will clinicians and patients intuitively know how to operate the pump? ° What are the default settings for the opiate concentrations in use? ° Do the drugs, units of delivery, and strengths appear in a logical sequence? • PCA pumps should be limited to a single model to promote proficiency with programming. • Before distributing the new pumps, the staff should verify that all pump default settings are set up as expected. • A warning label stating “For Patient Use Only” should be placed on the activation button. • Prescribing PCA • PCA standard order sets are required, and all sections must be completed. • The number of verbal orders to change doses should be kept as low as possible. • Orders for PCA opiates are always written in milligrams or micrograms, not in volume (milliliters). • The staff should check for patient allergies before selecting an opiate to be used for PCA. • Morphine is the opiate of choice. Hydromorphone can be used for patients who need very high doses of opiates. Meperidine (Demerol, Sanofi-Aventis) should be reserved for patients who are allergic to both morphine and hydromorphone. • To determine loading and maintenance doses, the staff should take into account other medications that the patient has received (e.g., analgesics taken at • • • • Before PCA Is Prescribed or Dispensed • Prescribers of PCA must undergo a privileging (credentialing) process to 8 P&T® • January 2008 • Vol. 33 No. 1 http://www.ismp.org
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