title: Five-year experience of critical incidents associated with patient-controlled analgesia in an Irish University Hospital.
abstract: BACKGROUND
  Patient-controlled analgesia (PCA) is a common and effective means of managing post-operative pain. We sought to identify factors that may lead to critical incidents (CIs) in patient safety when using PCA in our institution.
  
  
  METHODS
  An observational study of prospectively collected data of patients who received PCA from 2002 to 2006 was performed. All CIs were documented and analysed by staff members of the acute pain service (APS). Cause analysis of CIs was undertaken to determine if measures can be instituted to prevent recurrence of similar events.
  
  
  RESULTS
  Over eight thousand patients (8,240) received PCA. Twenty-seven CIs were identified. Eighteen were due to programming errors. Other CIs included co-administration of opioids and oversedation.
  
  
  CONCLUSIONS
  In our institution, the largest contributory factor to CIs with PCAs was programming error. Strategies to minimize this problem include better education and surveillance.
authors.affiliation: Department of Anaesthesia, Adelaide and Meath Hospital, Belgard Road, Tallaght, Dublin 24, Ireland. ishtiaqahmad99@hotmail.com
authors.forename: I
authors.initials: I
authors.lastname: Ahmad
authors.forename: A
authors.initials: A
authors.lastname: Thompson
authors.forename: M
authors.initials: M
authors.lastname: Frawley
authors.forename: P
authors.initials: P
authors.lastname: Hu
authors.forename: A
authors.initials: A
authors.lastname: Heffernan
authors.forename: C
authors.initials: C
authors.lastname: Power
mesh_terms: D016058:Analgesia, Patient-Controlled / Q000009:adverse effects*; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007494:Ireland; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000517:prevention & control; D011785:Quality Assurance, Health Care; D012984:Software; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data