(358) Medication errors associated with intravenous patient controlled analgesia: a descriptive analysis of 2005-2015 MEDMARX database

Abstract

Intravenous (IV) patient-controlled opioid analgesia (PCA) is a mainstay of the management of acute post-operative pain. While IV PCA has the benefit of allowing patient to self-titrate opioids to their level of pain and faster delivery of analgesics, their use is also accompanied by number of challenges, including medication errors, analgesic gaps, and proxy dosing. The objective of this study was to characterize medication errors associated with IV PCA therapy in hospital settings. A retrospective, descriptive analysis of 2005-2015 Quantros™ MEDMARX data was conducted and revealed 1,948 unique medication errors associated with opioid IV PCA occurring in hospitals during this time period. Based on the NCC MERP Index, 89.5 % of these errors were classified as non-harmful, 6.7% as harmful, and 3.8% as potential errors, with majority of these errors occurring during drug administration (55%) and dispensing (23%). Over a quarter (26.3%) of the errors were attributed to pump-related causes including improper use of pump and pump malfunction. Of the 130 harmful errors, 65% (84) occurred during drug administration. Major types of harmful errors included: improper dose/quantity (58.4%), omission error (23.1%), prescribing error (15.4%) and wrong administration technique (13.8%). The leading causes of harmful errors included human performance factors (57%), procedure or protocol not followed (43.8%), and improper pump use (33.8%). Of the 1383 errors that reached the patient, 27.8% required interventions to prevent serious/fatal complications. Despite the advantages of IV PCA, patients are still at risk of IV PCA-related errors. These findings indicate certain types of IV PCA-related errors may be preventable. There is an unmet need for novel PCA systems that could potentially circumvent certain medication errors commonly associated with IV PCA while still retaining the advantages of pain management associated with PCA. Supported by a grant from AcelRx Pharmaceuticals, Inc.