What’s New in the Patient Safety World
October 2012
Another PCA Pump Safety Checklist
In our February 21,
2012 Patient Safety Tip of the Week “Improving
PCA Safety with Capnography” we mentioned that the Physician-Patient
Alliance for Health & Safety (PPAHS) had a
workgroup addressing PCA safety. On their website are some
heart-wrenching stories about patients who died during PCA, likely as a result
of inadequate monitoring. We said we look forward to seeing that checklist when
it is ready. Well, the PPAHS has now
released that checklist for PCA pump safety (PPAHS
2012). Their website not only has the link to the PCA
Safety Checklist itself but also links to several columns and blogs
regarding PCA safety, PCA hazards, monitoring, capnography, etc. These are
excellent resources.
Another excellent resource on PCA safety is the San Diego
Patient Safety Council and the San
Diego Patient Safety Taskforce, which put together a tool
kit for PCA safety. It is a comprehensive document that discusses
assessment for PCA appropriateness, distinction between opioid naďve and opioid
tolerant patients, PCA patient education, pain assessment, sedation assessment,
respiratory assessment, monitoring, adjuvant therapies (eg. for treating side
effects of opioid therapy such as constipation, nausea and vomiting, pruritis),
multimodal pain management strategies, standardized order sets, and specific issues
related to equipment and products.
In our May 17, 2011 Patient Safety Tip of the Week “Opioid-Induced Respiratory Depression – Again!” we encouraged hospitals to perform their own FMEA (Failure Mode and Effects Analysis) on the PCA process and provided links to two tools we use when doing FMEA’s of the PCA pump process: the PCA Pump Audit Tool and the PCA Pump Criteria. And we hope that you’ll go back and look at the string of recommendations we made in our September 6, 2011 Patient Safety Tip of the Week “More Tips on PCA Safety”. We think you will find them extremely helpful. And don’t forget that most of the issues pertaining to patients on PCA pumps apply also to patients receiving postoperative opioids by other routes.
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
- January 4, 2011 Patient Safety Tip of the Week “Safer Use of PCA”
- July 13, 2010 Patient Safety Tip of the Week “Postoperative Opioid-Induced Respiratory Depression”
- May 12, 2009 Patient Safety Tip of the Week “Errors With PCA Pumps”
- September 21, 2010 Patient Safety Tip of the Week “Dilaudid Dangers”
- November 2010 What’s New in the Patient Safety World column “More on Preoperative Screening for Obstructive Sleep Apnea”
- February 22, 2011 Patient Safety Tip of
the Week “Rethinking
Alarms”
- May 17, 2011 Patient Safety Tip of the
Week “Opioid-Induced
Respiratory Depression – Again!”
- September 6, 2011 Patient Safety Tip of
the Week “More
Tips on PCA Safety”
- December 6, 2011 Patient Safety Tip of
the Week “Why
You Need to Beware of Oxygen Therapy”
- February
21, 2012 Patient Safety Tip of the
Week “Improving
PCA Safety with Capnography”
- Tools:
PCA
Pump Audit Tool and the PCA
Pump Criteria
References:
PPAHS
(Physician-Patient Alliance for Health & Safety)
PPAHS
(Physician-Patient Alliance for Health & Safety). Physician-Patient
Alliance for Health & Safety Announces New Expert Checklist for
Facilitating Safety of Hospital-Based Intravenous Patient-Controlled
Analgesia Pumps. July 17, 2012
PPAHS. PCA Safety
Checklist.
http://ppahs.files.wordpress.com/2012/07/pca-safety-checklist3.pdf
San Diego Patient
Safety Taskforce. Tool Kit: Patient Controlled Analgesia (PCA) Guidelines of
Care for the Opioid Naďve Patient. Published: December 2008
http://www.patientsafetycouncil.org/uploads/Tool-Kit-PCA_Dec_2008.pdf
http://www.patientsafetysolutions.com/