Implementing independent double checks for patient-controlled analgesia (PCA) pump programming.

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153 Background: Pain is the most common symptom experienced by oncology patients. Up to 90% of all patients with advanced cancer experience pain and 50% of those describe their pain as moderate to severe. The patient controlled analgesia (PCA) is commonly used to treat pain on the acute care oncology unit at The Massachusetts General Hospital (MGH). The PCA pump can be programmed incorrectly, resulting in over or under dosing of patients with opiates. Both the Federal Drug Administration (FDA) and the Institute for Safe Medication Practice (ISMP) recommend an independent double check (IDC) be done on error prone processes like the use of high alert medications. An IDC involves two clinicians separately checking (alone and apart from each other, then comparing results) the infusion settings in accordance with the physician’s order. Methods: The nurses on the acute care oncology unit at MGH were surveyed to determine their baseline understanding of an IDC. Training was conducted and a process for documentation implemented. A second intervention included further education initiatives such as posters of key points and a web-based knowledge survey of the IDC definition, process, and documentation. Results: Prior to the initial implementation 80% (32/40) of the nurses provided a partially correct definition of an IDC, 17.5% (7/40) an incorrect definition of an IDC and only 2.5% (1/40) provided a correct definition of an IDC. After the initial educational activities, a second knowledge survey was administered. Performance improved with only 13.4% (7/52) of the nurses missing one or more of the three questions on survey. After the initial education, of the 126 opportunities to document an IDC 21.4% (27/126) were done correctly. Performance improved to 80.7% (67/83) after the second intervention. Conclusions: Prior to implementing this IDC education, nurses at MGH did not have a clear understanding of what is required for an IDC of a PCA. This pilot education module was effective in decreasing the knowledge gaps and improving performance. Education must be concise and repetitive to change practice. Successful implementation of an IDC process improves the safety of a high-alert medication for the patient.