Five-year experience of critical incidents associated with patient-controlled analgesia in an Irish University Hospital

Irish Journal of Medical Science

Volumn 179, Issue 3, 2010, Pages 393-397

  Ahmad, I ^a   Thompson, A ^a   Frawley, M ^a   Hu, P ^a   Heffernan, A ^a   Power, C ^a  

^a ADELAIDE AND MEATH HOSPITAL   (Ireland)

Author keywords

Acute pain service; Critical incidents; Patient controlled analgesia

Indexed keywords

ANALGESIC AGENT; BENZODIAZEPINE DERIVATIVE; NALOXONE; NONSTEROID ANTIINFLAMMATORY AGENT; ONDANSETRON; OPIATE; PARACETAMOL;

ADULT; ANESTHESIA COMPLICATION; ARTICLE; BRADYPNEA; BREATHING RATE; CARDIOPULMONARY INSUFFICIENCY; FEMALE; HEALTH CARE QUALITY; HUMAN; HYPERCAPNIA; HYPOTENSION; HYPOXEMIA; MAJOR CLINICAL STUDY; MALE; MEDICAL DOCUMENTATION; MEDICATION ERROR; OBSERVATIONAL STUDY; PAIN; PATIENT CONTROLLED ANALGESIA; PATIENT SAFETY; PATIENT SELECTION; POSTOPERATIVE NAUSEA AND VOMITING; QUALITY CONTROL; RESPIRATION DEPRESSION; RISK ASSESSMENT; RISK FACTOR; SEDATION; SIDE EFFECT; STAFF TRAINING; UNCONSCIOUSNESS;

ANALGESIA, PATIENT-CONTROLLED; FEMALE; HOSPITALS, UNIVERSITY; HUMANS; IRELAND; MALE; MIDDLE AGED; PAIN, POSTOPERATIVE; QUALITY ASSURANCE, HEALTH CARE; SOFTWARE; SURGICAL PROCEDURES, OPERATIVE;

EID: 77955984020     PISSN: 00211265     EISSN: None     Source Type: Journal    
DOI: 10.1007/s11845-010-0482-6     Document Type: Article

References (30)

1. Hudcova J, McNicol E, Quah C et al (2006) Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev 4:CD003348 (18 October)
2. PH Sechzer 1968 Objective measurement of pain Anesthesiology 29 209 210 10.1097/00000542-196801000-00104
3. PH Sechzer 1971 Studies in pain with analgesic-demand system Anesth Analg 50 1 10 10.1213/00000539-197101000-00001 1:STN:280:DyaE3M7gtlCmsw%3D%3D 5100236
4. FA Khan S Khimani 2007 Customer focused incident monitoring in anaesthesia Anaesthesia 62 6 586 590 10.1111/j.1365-2044.2007.05070.x 1:STN:280:DC%2BD2s3psF2ntQ%3D%3D 17506737 (Pubitemid 46796320)
5. Dave M et al (2003) Quality assurance in prescribing of patient-controlled analgesia and long acting opiods. Am J Health Syst Pharm 60(14)
6. PP Chen, et al. 1998 Incident reporting in acute pain management Anaesthesia 53 730 735 10.1046/j.1365-2044.1998.00407.x 1:STN:280: DyaK1M%2FhsVanuw%3D%3D 9797515 (Pubitemid 28391377)
7. B Anderson S Nilsson 1964 Studies in the reliability and validity of critical incident technique J Appl Psychol 48 398 403 10.1037/h0042025
8. RK Webb M Currie CA Morgan, et al. 1993 The Australian Incident Monitoring Study: an analysis of 2000 incident reports Anaesth Intensive Care 21 520 528 1:STN:280:DyaK2c%2FpvFCmsQ%3D%3D 8273871 (Pubitemid 23311279)
9. TA Buckley TG Short YM Rowbottom, et al. 1997 Critical incident reporting in intensive care unit Anaesthesia 52 403 409 10.1111/j.1365-2044.1997.094- az0085.x 1:STN:280:DyaK2szgvVOltw%3D%3D 9165956
10. SL Tsui WN Tong M Irwin, et al. 1996 The efficacy, applicability and side-effects of postoperative intravenous patient-controlled morphine analgesia: an audit of 1233 Chinese patients Anaesth Intensive Care 24 658 664 1:STN:280:DyaK2s7is1eqtQ%3D%3D 8971312
11. PE Macintyre 2001 Safety and efficacy of patient-controlled analgesia Br J Anaesth 87 36 46 10.1093/bja/87.1.36 1:CAS:528:DC%2BD3MXls1Ohtro%3D 11460812 (Pubitemid 32631674)
12. DM Popping PK Zahn HK Van Aken, et al. 2008 Effectiveness and safety of postoperative pain management: a survey of 18925 consecutive patients between 1998 and 2006; a database of prospectively raised data Br J Anaesth 101960 832 840 10.1093/bja/aen300
13. CW Cheung CL Ying LH Lee, et al. 2009 An audit of postoperative intravenous patient-controlled analgesia with morphine: evolution over the last decade Eur J Pain 13 5 464 471 10.1016/j.ejpain.2008.05.013 1:CAS:528: DC%2BD1MXktFagtrY%3D 18602851
14. A Shapiro E Zohar M Kantor, et al. 2004 Establishing a nurse-based, anesthesiologist-supervised inpatient acute pain service: experience of 4,617 patients Clin Anesth 16 6 415 420 10.1016/j.jclinane.2003.11.002 (Pubitemid 39573000)
15. CT Hung LL Lau CK Chan, et al. 2002 Acute pain services in Hong Kong: facilities, volume, and quality Hong Kong Med J 8 3 196 201 1:STN:280: DC%2BD38zht12htw%3D%3D 12055366
16. L Lin R Isla K Doniz, et al. 1998 Applying human factors to the design of medical equipment: patient-controlled analgesia Clin Monit Comput 14 4 253 263 10.1023/A:1009928203196 1:CAS:528:DyaK1MXovV2ruw%3D%3D (Pubitemid 28398504)
17. ECRI 2006 Patient-controlled analgesic infusion pumps Health Devices 35 1 5 35
18. MR Cohen J Smetzer 2005 Patient-controlled analgesia safety issues J Pain Palliat Care Pharmacother 19 1 45 50 15814514
19. Institute for Safe Medication Practices (2004) Misprogramming a PCA Pump? It's Easy! ISMP safety alert, 29 July. Available at http://www.ismp.org/ Newsletters/acutecare/articles/20040729-2.asp. Accessed 1 August 2007
20. Institute for Safe Medication Practices (2003) Safety issues with patient controlled analgesia part 1-how errors occur. ISMP safety alert, 10 July. Available at http://www.ismp.org/Newsletters/acutecare/articles/20030710.asp. Accessed 1 August 2007
21. M Grissinger 2008 Safety and patient-controlled analgesia: part 2: how to prevent errors Pharm Ther 33 1 8 9
22. RW Hicks V Sikirica W Nelson, et al. 2008 Medication errors involving patient controlled analgesia Am J Health Syst Pharm 65 5 429 440 10.2146/ajhp070194 18281735 (Pubitemid 351358345)
23. CS Hankin J Shein JA Clark, et al. 2007 Adverse events involving intravenous patient controlled analgesia Am J Health Syst Pharm 64 14 1492 1499 10.2146/ajhp060220 17617499 (Pubitemid 47077132)
24. KJ Vincent, et al. 2003 Programming errors contribute to death from patient-controlled analgesia: case report and estimate of probability Can J Anesth 50 4 328 332 10.1007/BF03021027
25. LC Looi-Lyons FF Chung VW Chun, et al. 1996 Respiratory depression: an adverse outcome during patient controlled analgesia therapy J Clin Anesth 8 2 151 156 10.1016/0952-8180(95)00202-2 1:CAS:528:DyaK2sXjsFagsbw%3D 8695099 (Pubitemid 26073981)
26. MA Ashburn G Love NL Pace 1994 Respiratory-related critical events with intravenous patient-controlled analgesia Clin J Pain 10 1 52 56 10.1097/00002508-199403000-00007 1:STN:280:DyaK2c3ltFSitQ%3D%3D 8193444
27. S Syed JE Paul M Hueftlein, et al. 2006 Morphine overdose from error propagation on an acute pain service Can J Anesth 53 6 586 590 10.1007/BF03021849 16738293
28. M Grissinger 2008 Misprogram a PCA pump? It's easy PT 33 10 567 568
29. HH Chen ML Yeh HJ Yang 2005 Testing the impact of multimedia CD of PCA on pain knowledge and pain relief in patients receiving surgery Int J Med Inform 74 6 437 445 10.1016/j.ijmedinf.2005.04.003 15936246 (Pubitemid 40840786)
30. ML Yeh HH Chen PH Liu 2005 Effects of multimedia with printed nursing guides in education on self efficacy and functional activity and hospitalization in patients with hip replacement Patient Educ Couns 57 2 217 224 10.1016/j.pec.2004.06.003 15911196 (Pubitemid 40724379)