Importance of Proper Patient-Controlled Analgesia (PCA) Utilization and Programming

In a recent patient safety event, a high-dose PCA medication was not scanned into the PCA pump.  The wrong medication was manually selected from the PCA medication library which resulted in the incorrect medication dosage being administered to the patient.  The patient experienced decreased oxygen saturations and opioid-induced respiratory depression.  Naloxone was administered and the patient returned to baseline. 

Staff caring for patients should review these steps:

1. In Epic MAR: Scan the medication bar code

   

2. At the PC Unit (brain):  Scan your badge, then scan the syringe QR code (square).

   

3. Review the drug and concentration that populates at the PCA pump.  
4. Perform an independent double check at initial set-up and changes in rate or syringe.
5. Review compliance with the “Five Rights” of medication safety: the right patient, the right drug, the right dose, the right route, and the right time.  In pediatrics, recalculate the dose for the patient’s weight. 

Safe practices to prevent this type of event:

• Manual selection and entry of medications increases the possibility of selecting the wrong drug and/or concentration of a drug.
• If the label does not scan, be persistent. Reposition and assure alignment of the QR code (square). If difficulty continues, stop and contact nursing leadership.
• Do not bypass scanning and start infusion.