Five-year experience of critical incidents associated with patient-controlled analgesia in an Irish University Hospital.
AffiliationDepartment of Anaesthesia, Adelaide and Meath Hospital, Belgard Road, Tallaght,, Dublin 24, Ireland. firstname.lastname@example.org
MeSHAnalgesia, Patient-Controlled/*adverse effects
Pain, Postoperative/prevention & control
Quality Assurance, Health Care
Surgical Procedures, Operative/statistics & numerical data
MetadataShow full item record
CitationIr J Med Sci. 2010 Sep;179(3):393-7. Epub 2010 May 21.
JournalIrish journal of medical science
AbstractBACKGROUND: 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. CONCLUSION: In our institution, the largest contributory factor to CIs with PCAs was programming error. Strategies to minimize this problem include better education and surveillance.