Medication errors involving intravenous patient-controlled analgesia: results from the 2005–2015 MEDMARX database. (August 2018)

• Record Type: Journal Article
• Authors: Mohanty, Maitreyee; Lawal, Oluwadolapo D.; Skeer, Margie; Lanier, Ryan; Erpelding, Nathalie; Katz, Nathaniel
• Is Part Of: Therapeutic advances in drug safety. Volume 9:Number 8(2018)
• Page Start: 389
• Page End: 404
• Publication Date: 2018-08
• Subjects: acute pain -- intervention -- medication errors -- patient-controlled analgesia; Pharmacoepidemiology -- Periodicals; Drugs -- Side effects -- Periodicals; Drugs -- Toxicology -- Periodicals; Pharmaceutical Preparations -- adverse effects -- Periodicals; Toxicology -- Periodicals; 615.70405
• DOI: 10.1177/2042098618773013
• Languages: English
• ISSNs: 2042-0986

Abstract

Background: The aim of this study was to determine the current magnitude and characteristics of intravenous patient-controlled analgesia (IV-PCA) errors, and to identify opportunities for improving the PCA modality. Methods: We conducted a descriptive analysis of IV-PCA medication errors submitted to the MEDMARX database. Events were restricted to those occurring in inpatient hospital settings between 1 January 2005 and 31 December 2015. IV-PCA errors were classified by error category, cause of error, error type, level of care rendered, and actions taken. Results: A total of 1948 IV-PCA errors were identified as potential errors (3.9%), nonharmful errors (89.5%), or harmful errors (6.7%) based on the National Coordinating Council for Medication Error Reporting and Prevention taxonomy for categorizing medication errors. Of these, 19.1% required a clinical intervention to address the deleterious effects of the error, indicating an underestimation of the risks associated with IV-PCA errors. The most frequent types of errors were improper dose/quantity (43.2%) and omission errors (19.9%). While human performance deficit was the leading cause of error (50.2%), other common causes included failure to follow procedure and protocol (42.2%) and improper use of the pump (22.7%). Although remedial actions were often taken to prevent error recurrence, actions were taken to rectify the systemic deficits that led to errors in only a minority of cases (11.8%). Conclusion: Preventable errors continue to pose unnecessary risks to patients receiving IV-PCA. Multimodal analgesic regimens and novel PCA systems that reduce human error are needed to prevent errors while preserving the advantages of PCA for the management of acute pain.