Systems Thinking 239

pump. However, because this therapeutic intervention combines inherently error-prone

devices, and narcotics, serious unintended outcomes have frequently occurred.
Fortunately, by identifying specific issues, risks associated with this technology
can be reduced. Table 7.2 summarizes some of the issues surrounding the use of PCA
pumps and appropriate solutions.

TABLE 7.2. Patient-Controlled Analgesia (PCA) Problems and Safety

Recommendations.

Problem Description Safety Recommendations

PCA by proxy When another person (health
professional, family member)
administers a dose of medication
instead of the patient’s dosing
themselves.
Can lead to oversedation,
respiratory depression, and
death. Patients must control
the PCA, but a sedated patient
cannot press the button, thereby
overdosing.
Warn patients, family members, and
visitors about the dangers of PCA by
proxy.
Place warning labels on activation
buttons that state “FOR PATIENT USE
ONLY.”
Keep PCA flowsheets at the bedside
to document PCA doses and patient
monitoring.

Improper Only patients who have the
patient selection mental alertness and sufficient
and education cognitive, physical, and
psychological ability should use a
PCA pump
Can lead to inadequate pain
control or oversedation.
Teaching patients during the
immediate postoperative period
is ineffective if the patient is too
groggy to understand. This has
often led to poor pain control in
the first twelve hours following
surgery.
Check patient allergies, which
should be visible on the MAR, before
initiating PCA.
Educate patients preoperatively about
PCA use.
Establish patient selection criteria.
In general, infants, young children,
and confused patients are not suitable
candidates to use a PCA pump.

(Continued)

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