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Daily News: Patient-controlled Iv Error-prone
Errors in intravenous patient-controlled analgesia are four times more likely to result in patient harm than errors that occur with other medications, The Joint Commission said in coverage of its December Journal on Quality and Patient Safety.
Patient-controlled analgesia is an error-prone process because "orders must be written, reviewed, and then accurately programmed into sophisticated delivery devices for patients to be pain free," according to lead author Rodney W. Hicks, MSN, PhD, MPA, a nursing professor at Texas Tech University who specializes in patient safety.
The study of more than 9,500 patient-controlled analgesia errors over five years showed patient harm in 6.5% of incidents compared with 1.5% of general medication errors. Harm ranged from suppressed respiration to inadequate pain relief to death. Most errors involved either the wrong dosage or the wrong drug and were caused by human factors, or equipment or communication breakdowns, according to the study. It was based on voluntary reports to the United States Pharmacopeia MEDMARX Program.
"Healthcare organizations should now plan to make the process safer," Hicks said, recommending three strategies: simplified technical equipment with easy-to-follow setup instructions for care-givers; use of barcodes and an electronic medication administration record to reduce wrong-medication errors; and asking pharmacists to design easily understood and standardized forms to be used by all prescribers of patient-controlled analgesia.
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