Reducing Errors With Patient-Controlled Analgesia Pumps: Q&A With Bryanne Patail of the National Center for Patient Safety

Bryanne Patail, biomedical engineer at the U.S. Department of Veterans Affairs, National Center for Patient Safety, discusses patient-controlled analgesia (PCA) pumps and what the Veterans Health Administration has done to reduce errors and improve patient safety. This interview was conducted with Michael Wong of the Physician-Patient Alliance for Health & Safety.


Q: What concerns do you have with PCA pumps?


Bryanne Patail: As I reported at the AAMI/FDA Infusion Device Summit (pdf), VHA has been conducting root cause analyses since 1999. In looking at infusion pumps, we found that more the 13 percent (129 in all) involved two types of infusion pumps. Of these 129 events, 60 related to general-purpose pumps and 69 to PCA pumps. In other words, more than 50 percent of these events involved PCA pumps — roughly a 50/50 split between general-purpose and PCA pumps. However, there are about 10 times as many general-purpose pumps in use across the VA system than PCA pumps. This suggests that incidents with PCA pumps are about 10 times more than with general-purpose pumps. That's significant!


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Q: What did VHA do about this high PCA pump incidence rate?


BP: One action that VHA has taken to address this high error incident rate is to use a PCA pump that has an integrated end tidal CO2 monitor or capnograph. A capnograph measures in real-time the adequacy of ventilation. Using this technology could prevent more than 60 percent of adverse events related to PCA pumps.


In addition, we developed a standard protocol that looks at the other key issues that need to be addressed for safe use of PCA pumps: human factors (communication, training, fatigue and scheduling); the environment and equipment, rules, policies and procedures, and barriers and controls.


Q: From your experience, what would you recommend to other healthcare providers to reduce their PCA-related errors?


BP: Use of PCA pumps is a process, and improving that process is an area that involves many stakeholders. In looking at fixes, they can be categorized as strong, intermediate or weak fixes. The strongest fix for PCA pumps is a forcing function, such as an integrated end tidal CO2 monitor that will pause the pump if a possible over infusion occurred. So, healthcare providers should first look at these strong fixes. There they will see the most impact on reducing errors and improving patient safety.


Learn more about the Physician-Patient Alliance for Health & Safety.


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