USP Quality Review

Recommendations Based on Analysis of Medication Errors

General

Conduct a Failure Modes & Effects Analysis (FMEA) for existing pumps, as well as for new pumps that are brought into the facility. Consider what default settings are preprogrammed. Consider if the pumps can be programmed by drug (e.g., morphine PCA vs. hydromorphone PCA). Consider if the pump resets to a default (other than "000," which would require active entry) after it turns off.

Include bar codes on all PCA medications in facilities where point-of-care bar code systems or other item identification technologies (i.e., Radio Frequency Identification, etc.) are implemented.

Review policies concerning patient's own pump being used in the hospital.

Educate patients, family members, and staff (including physical therapists, X-ray technicians, etc.) on the use of the pumps.

STAFF: Require proper and complete training and demonstration of competency before staff is permitted to work with pumps.
PATIENTS AND FAMILY MEMBERS: Written instructions should be provided to patients. Instruct family members NOT to administer PCA doses-PCA by definition should be administered at the patient's perception of need. Document education of patient and family members.

Dosing errors are usually by a factor of 10. Errors include the following:

Underdoses when lockout is at 4 hours (default) instead of 1 hour.
Order calls for 1 mg/hour but the pump is set at 0.1 mg/hour.
Order calls for 0.05 mg but the pump is set at 0.5 mg.
Other errors include insertion of the wrong drug or wrong concentration in the PCA device.

Pumps should have upstream occlusion alarms.

Educate staff on sound-alike and look-alike drugs, especially when bar code technology is not part of the existing system. Many wrong drug errors with PCA pumps are due to name confusion (e.g., morphine vs. hydromorphone vs. meperidine). Auxiliary labeling or posted warnings could be used to highlight differences. Limit the number of products and strengths used/stocked in the facility. Create alerts in computer systems with dosing limits specific to the drug being selected. Do not store sound-alike or look-alike drugs together in a single drawer of the dispensing cabinet on the floor. To view USP's list of similar drug names, visit www.usp.org/hqi/practitionerPrograms/newsletters/qualityReview/qr792004-04-01.html. USP also has a list of tips for using this resource at www.usp.org/hqi/practitionerPrograms/newsletters/practitionerReportingNews/prn1182004-09-10.html.

Prescribing

Lockouts should be required with bolus dosing.

Have standing orders for all medications used in PCAs. Be certain that standing order forms have complete information to avoid handwriting information or drug names. Include specific dosing guidelines and protocols for individualizing therapy to patients based on pain response. Standardize concentrations available for PCA drugs.

If using preprinted order forms, prohibit writing over information on the form. For example, one provider using a PCA order form that was preprinted with "meperidine" crossed out the drug and wrote "hydromorphone" without changing the basal rate, loading dose, and lockout dose, which caused the patient to become unresponsive, requiring an antidote.

Avoid duplication of pain management therapy when PCA is in use. Develop protocols to transition to oral therapy from PCA therapy.

Dispensing

Standardize the strengths/concentrations available in your facility. Be sure physicians are aware of the standard concentrations in use. If higher concentrations are needed for a particular patient or certain settings, conduct FMEA to ensure additional safeguards are in place.

Separate PCA syringe locations in automated dispensing systems to prevent selection of the wrong drug.

Administering

Double-check clamp (to open position) before closing the pump.

Check that the pump is turned on.

Check whether connections are to IV or epidural lines to prevent wrong-route errors.

Check for kinked tubing in the pump door. Despite a kink in the tubing, at times no alarm may sound and the volume may be counting down.

Perform double checks for initial setup and maintenance, and dose changes/change orders.

Standard orders should be on the medication administration record.

Conduct staff education on the importance of not administering oral medications (i.e., narcotics and controlled substances) to a patient with a PCA in use unless specifically ordered.

Temporary nurses (agency or supplemental staff) need to review and be familiar with policies and protocols regarding PCAs and demonstrate competency in the use of this technology.

Do not accept defaults blindly.

Set pumps to be programmed in mg, NOT mL.

Pumps should be assessed on a regular basis.

Monitoring

If patient complains of pain, reassess pump settings. Check that the basal rate has been entered. Also check that the tubing is not kinked.

Acknowledgment is given to the following members of the USP Safe Medication Use Expert Committee, who provided review and comment on these recommendations:

Mark Sullivan, PharmD, MBA, BCPS - Vanderbilt University Medical Center
Marjorie Shaw Phillips, RPh, MS, FASHP - Medical College of Georgia Health System
Philip Schneider, MS - Ohio State University