title: Evaluation of use of electronic patient controlled analgesia pumps to improve patient safety in an academic medical center.
abstract: Patient controlled analgesia (PCA) and Patient-controlled epidural analgesia (PCEA) pumps are methods of pain control with complex smart infusion devices and are widely used in hospitals. Smart PCA/PCEA pumps can be programmed with the dose and rate of medications within pre-set ranges. However, adverse effects have been reported associated with these pumps' use. In this paper, we describe a prevalence observational study where observers used an electronic data collection tool to record pump settings and medications with PCA pumps, corresponding medication orders to identify errors. The results showed that there were many labeling and tubing change tag errors, which were a violation of hospital policy. A few potential harmful medication errors were identified but no critical errors. Study results suggest the importance of a standard process of PCA pump use. Next steps include implementing a safety bundle for improving PCA practice to support safe and effective pain management.
authors.affiliation: General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Kumiko
authors.initials: K
authors.lastname: Ohashi
authors.affiliation: General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Patricia
authors.initials: P
authors.lastname: Dykes
authors.affiliation: Center for Excellence in Nursing Practice, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Mcintosh
authors.affiliation: Center for Excellence in Nursing Practice, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Buckley
authors.affiliation: General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Catherine
authors.initials: C
authors.lastname: Yoon
authors.affiliation: Center for Excellence in Nursing Practice, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Carol
authors.initials: C
authors.lastname: Luppi
authors.affiliation: Center for Excellence in Nursing Practice, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Anne
authors.initials: A
authors.lastname: Bane
authors.affiliation: General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: David W
authors.initials: DW
authors.lastname: Bates
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data; D016058:Analgesia, Patient-Controlled / Q000706:statistics & numerical data*; D001900:Boston / Q000453:epidemiology; D006801:Humans; D007260:Infusion Pumps / Q000706:statistics & numerical data*; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data*; D010355:Patient Identification Systems; D061214:Patient Safety / Q000706:statistics & numerical data*; D015995:Prevalence; D012646:Self Administration