Pharmacy and Therapeutics - January 2008 - (Page 9) MEDICATION ERRORS home, intraoperative medications) or is currently taking (e.g., antihistamines, nighttime sedatives). • The appropriateness of PCA therapy should be reassessed at regular intervals. istration record (MAR) before PCA is begun. PCA should be connected to a port close to the patient to avoid dead space, and the infusion line should be prominently labeled at this connection to avoid mix-ups with other lines. Laminated instructions for programming PCA pumps should be provided for nurses who initiate PCA only rarely. Two clinicians should independently double-check the patient’s identification, the drug selected and its concentration, the PCA pump settings, and the line attachment before PCA is used and before a pump refill or a programming change is made. Bedside bar-coding can be used to verify the patient and the drug concentration, but pump settings might still need to be double-checked. Nurse-controlled PCA should be avoided unless special monitoring is in place. PCA settings should be verified during each shift immediately after an updated report about the patient’s condition is received. Concomitant opiates should not be administered; an alert should appear on the medication administration record to this effect. Oxygen and naloxone should be readily available. Patients should be taught about the proper use of PCA during the preoperative testing visit so that they are not too groggy to understand. Family members and visitors should be warned about the danger of PCA by proxy. quently during the first 24 hours and at night, when hypoventilation and hypoxia tend to occur. The staff should become familiar with risk factors that can increase respiratory depression (e.g., obesity or low body weight, concomitant medications that potentiate opiates, and pre-existing conditions such as asthma and sleep apnea). The staff should determine the level of enhanced monitoring (e.g., capnography, apnea alarms at night) that would be required if these patients use PCA. Staf f members should identify the infrequent situation in which criticalcare patients might be suitable for nurse-controlled analgesia and should indicate the level of enhanced monitoring that would be required for these patients. Health care personnel should not rely on pulse oximetry readings alone to detect opiate toxicity. Because capnography is currently not available for all PCA patients, its use should be reserved for patients with a heightened risk of toxicity and for patients who are appropriate candidates for nurse-controlled analgesia. Flow sheets should be kept at the bedside to document the PCA doses and patient monitoring. The use of naloxone should be monitored to identify PCA-related adverse events. • • Dispensing PCA • One standard concentration should be established for each opiate used for PCA. • Only standard concentrations of morphine and hydromorphone should be stocked in patient-care units. Meperidine for PCA should be dispensed from the pharmacy. • To avoid mix-ups, personnel should separate stored hydromorphone from morphine in the pharmacy as well as in patient-care units. • Any patient allergies should be listed in the interactive-allergy field in the patient’s profile before PCA orders are entered into the computer. • Maximum dose limits for PCA opiates should be set in the pharmacy computer so that an alert appears if a safe dose is exceeded during order entry. • If an opiate is being dispensed in a nonstandard concentration, staff members should affix a prominent warning to the label. • Prefilled syringes, bags, and cassettes should be used whenever possible. The pharmacy should prepare all PCA products that are not commercially available. • A pharmacist should review all PCA orders before PCA is initiated unless the pharmacist is off-site. • The pharmacist should suggest renal dose adjustments or an alternative opiate when appropriate. • If meperidine is used for PCA, the pharmacy should set dose limits and should reassess the patient every 24 hours. • “Tall man” lettering should be used on pharmacy-applied labels for HYDROmorphOne to help prevent confusion with morphine. • Clinicians should be alerted to potential drug shortages of PCA opiates. If a shortage is encountered, an alternative drug with clear dosing instructions should be recommended. • • • • • • • • • • • • • • Monitoring the Effects of PCA • A standard measurement scale should be established to assess the patient’s level of pain. • Monitoring requirements should be developed for patients who are receiving PCA. At a minimum, the patient’s level of pain, alertness, vital signs, and rate and quality of respirations should be evaluated every four hours. • The staff must be alert for signs of oversedation. • To accurately assess the level of sedation, personnel should evaluate all patients showing a minimal response to verbal or tactile stimulation. • Patients should be monitored more fre- The reports described in this column were received through the USP–ISMP Medication Errors Reporting Program (MERP). Errors, close calls, or hazardous conditions may be reported on the ISMP (www.ismp. org) or the USP (www.usp.org) Web site or communicated directly to ISMP by calling 1-800-FAILSAFE or via e-mail at ismpinfo@ismp.org. I Initiating PCA • All patient allergies should appear prominently on the medication admin- Vol. 33 No. 1 • January 2008 • P&T® 9 http://www.ismp.org http://www.ismp.org http://www.usp.org
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