1. Kennedy, Maureen Shawn MA, RN

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According to a recent report from the Center for the Advancement of Patient Safety of the U.S. Pharmacopeia (USP), patient-controlled analgesia (PCA) pumps, while proven effective in pain management, continue to be a factor in harmful medication errors. From September 1998 through August 2003, 5,377 errors related to PCA were submitted to the USP's medication-error databases-MEDMARX and the USP Medication Errors Reporting (MER) Program with 7.9% of them classified as having caused harm. (In general, the percentage of medical errors that result in harm is about 2%.) The most common errors were the administration of an improper dose (38.9%), the use of an unauthorized drug (18.4%), and an error of omission (17.6%). Less common but still prevalent were prescription errors (9.2%), incorrect administration techniques (4.8%), and the administration of extra doses (4.7%).


The report provides recommendations aimed at reducing the number of errors: placing bar codes on all PCA medications; educating patients, family members, and hospital staff in the proper use of the pumps (family members must be instructed not to administer PCA doses, given that the medication by definition must be administered according to the patient's perception of the need for pain relief), with emphasis on the fact that dosing errors usually occur by a factor of 10 (for example, an order calls for 1 mg/hour, but the pump is set at 0.1 mg/hour); and the need to watch out for "sound-alike and look-alike drugs" (not confusing morphine with hydromorphone, for example). For the complete report, visit -Dalia Sofer

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