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    Five-year experience of critical incidents associated with patient-controlled analgesia in an Irish University Hospital.

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    Authors
    Ahmad, I
    Thompson, A
    Frawley, M
    Hu, P
    Heffernan, A
    Power, C
    Affiliation
    Department of Anaesthesia, Adelaide and Meath Hospital, Belgard Road, Tallaght,, Dublin 24, Ireland. ishtiaqahmad99@hotmail.com
    Issue Date
    2012-02-01T10:48:52Z
    MeSH
    Analgesia, Patient-Controlled/*adverse effects
    Female
    Hospitals, University
    Humans
    Ireland
    Male
    Middle Aged
    Pain, Postoperative/prevention & control
    Quality Assurance, Health Care
    *Software
    Surgical Procedures, Operative/statistics & numerical data
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    Citation
    Ir J Med Sci. 2010 Sep;179(3):393-7. Epub 2010 May 21.
    Journal
    Irish journal of medical science
    URI
    http://hdl.handle.net/10147/207876
    DOI
    10.1007/s11845-010-0482-6
    PubMed ID
    20495886
    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. 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.
    Language
    eng
    ISSN
    1863-4362 (Electronic)
    0021-1265 (Linking)
    ae974a485f413a2113503eed53cd6c53
    10.1007/s11845-010-0482-6
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    Tallaght University Hospital

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