USP Quality Review

No. 81, Issued September 2004

Data Analysis

USP examined medication errors submitted to its MEDMARX® and USP Medication Errors Reporting (MER) Program from September 1, 1998, through August 31, 2003. To obtain PCA errors in MEDMARX, a text search for "PCA" in the Error Description field was conducted. Together, both programs yielded a total of 5,377 records. A total of 425 records (7.9%) were categorized as harmful (Category E-I¹) (Table 1). Given that the average overall harm rate for error reports submitted to MEDMARX over the past several years has been approximately 2 percent, it appears that when PCA pumps are involved, the chance for patient harm increases more than 3.5 times.

Table 1. PCA-Related Errors

Error Category¹ Count Percent %
A 474 8.8%
B 1288 24%
C 2,568 47.8%
D 622 11.6%
E 387 7.2%
F 26 0.5%
G 0 0%
H 7 0.1%
I 5 0.1%
Total       5,377

¹ For complete Error Category definitions, visit www.nccmerp.org/medErrorCatIndex.html

The most common types of error involving PCA pumps were Improper dose/quantity (38.9%), Unauthorized drug (18.4%), and Omission error (17.6%) (Table 2).

Table 2. Types of Error¹

Types of Error Count Percent %
Improper dose/quantity 1,873 38.9%
Unauthorized drug 887 18.4%
Omission error 846 17.6%
Prescribing error 443 9.2%
Wrong administration technique 230 4.8%
Extra dose 227 4.7%
Wrong drug preparation 203 4.2%
Wrong time 160 3.3%
Wrong patient 118 2.5%
Wrong dosage form 79 1.6%
Wrong route 29 0.6%
Deteriorated/Expired product 15 0.3%
Total     5,110

¹ Based on 4,812 records, making 5,110 selections for Type of Error