First, the activation button looks just like a nurse call bell, so patients have inadvertently given themselves a dose of analgesic while believing they were pressing the button to call a nurse.
Another problem is that, with lockout intervals set, unless the pump provides some visual or auditory feedback, patients cannot tell whether the press of the button has resulted in the actual delivery of medication. As a result, some patients press the button more frequently than they would with proper feedback, and others become frustrated and give up, resulting in undertreatment of pain. While pump manufacturers are required to perform human factors testing, this regulation is loosely enforced and these types of design problems may not be identified up front because practitioners and patients are not closely involved in the testing procedures.
Inadequate staff training. Entering a PCA prescription into a pump requires a number of steps. However, nurses may not always receive adequate training in pump programming, or they may not retain their proficiency once trained if multiple pumps are in use or if PCA is encountered infrequently. Additionally, prescribers may not undergo a credentialing process designed to verify proficiency with this form of pain management.
Prescription errors, including improper drugs or doses, have resulted. Prescription errors. The PCA order itself can be a source of error. Physicians have made mistakes in converting an oral opiate dose to the IV route most problematic is hydromorphone, which has an oral to IV conversion range of to They have prescribed a drug to which the patient is allergic, and have selected an opiate that is not appropriate for the patient meperidine in patients with renal impairment.
Occasionally, one opiate has been prescribed but the accompanying dose has been appropriate for a different opiate. Even with correct PCA orders, clinicians have been known to mishear or misread verbal or written orders, sometimes leading to serious errors. Concurrent orders for other opiates oral or parenteral while PCA is in use has also resulted in opiate toxicity. As of yet, none of the PCA pumps have the safety features available in new general purpose "smart pumps," which alert when maximum doses or flow rates are exceeded.
Again, we thank our readers for giving us feedback about PCA errors. The information provided allowed us to share insightful examples describing just how PCA errors have happened. The nurse was comfortable telling the physician that there had been a "problem" with the patient's digoxin, but she spoke in a hushed tone. The nurse then added that she would have to tell him the rest of the details after the charge nurse moved out of earshot.
Luckily, the patient, who was already on telemetry, showed no signs of toxicity over the next several days. Despite encouragement from the pharmacist, the error was never reported within the facility. Thus, the opportunity for other clinicians and managers to learn from this mistake was lost because something-perhaps fear of reprisal- prevented this nurse from involving her charge nurse after she made an error.
From these, best practices that promote error reporting can be identified. These best practices fall into six categories that impact the quantity and quality of reports see Table 1, below. Those who receive and act on error reports must earn the trust of reporters and prove that the program is sensitive to reporters' concerns, particularly fear of punishment for making and reporting errors. Feelings of trust are fostered by leaders who demonstrate an unequivocal passion for safety, acknowledge the high-risk nature of healthcare and human fallibility, and use errors to assess system performance, not staff performance.
What is needed is a just culture in which workers are encouraged to provide essential safety information without fear of being judged or treated unfairly in the wake of an error. Those who receive reports must keep the identity of the reporter, workers involved in the errors, and the location of the event, confidential to prevent undue embarrassment or undesirable attention. Anonymity when reporting is not recommended, as those who receive the report would not be able to talk to the reporter or others involved in an error to learn about the causative factors.
Anonymity also signals to reporters that it may not be safe to provide their identity or location, which trumps the idea of trustworthiness. Removing identities after the error has been fully investigated is an option, though. Clear and easy. Those who receive reports must pay attention to the format and length of the required report.
If the expected report is too long, it will stifle reporting; if the report is too short, you may not get enough information to make it useful. Instead of broad, general questions, the report should prompt for a narrative description of the event and ask questions that are specific to the type of event e. For example, a reporting format for medication hazards or errors should ask whether the event involved missing information about the patient or drug, communication problems, labeling and packaging problems, drug storage problems, environmental problems, and so on click here for a sample format.
Register Now. Introduction Visual similarities and confusing or absent presentation of important information on medication container labels, carton labels, and product packaging have frequently contributed to medication errors in the US. Recommendations Managing the risks associated with similar or confusing drug labeling and packaging is an industry-wide obligation. References Berman A. Reducing medication errors through naming, labeling, and packaging.
J Med Syst. Fact sheet: FDA at a glance. November 18, Drug applications for over-the-counter OTC drugs. March 31, Am J Health-Syst Pharm. Access this Free Resource You must be logged in to view and download this document. These and allied standards-setting activities are outlined in the USP Board of Trustees' new strategic plan www.
USP began collecting medication error data through its own programs in , but has been involved in analyzing such data for more than 30 years. USP found early on that information gleaned from error records added a medication safety component to its product standards and later led the way for its work in practice standards. USP also played an important role in the drafting and enactment of legislative changes such as the Patient Safety and Quality Improvement Act of USP continues its year commitment to medication safety through its core mission of standards setting.
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