Medication errors involving intravenous patient-controlled analgesia: results from the 2005-2015 MEDMARX database

Abstract

Background: The aim of this study was to determine the current magnitude and characteristics of intravenous patient-controlled analgesia (IV-PCA) errors, and to identify opportunities for improving the PCA modality.

Methods: We conducted a descriptive analysis of IV-PCA medication errors submitted to the MEDMARX database. Events were restricted to those occurring in inpatient hospital settings between 1 January 2005 and 31 December 2015. IV-PCA errors were classified by error category, cause of error, error type, level of care rendered, and actions taken.

Results: A total of 1948 IV-PCA errors were identified as potential errors (3.9%), nonharmful errors (89.5%), or harmful errors (6.7%) based on the National Coordinating Council for Medication Error Reporting and Prevention taxonomy for categorizing medication errors. Of these, 19.1% required a clinical intervention to address the deleterious effects of the error, indicating an underestimation of the risks associated with IV-PCA errors. The most frequent types of errors were improper dose/quantity (43.2%) and omission errors (19.9%). While human performance deficit was the leading cause of error (50.2%), other common causes included failure to follow procedure and protocol (42.2%) and improper use of the pump (22.7%). Although remedial actions were often taken to prevent error recurrence, actions were taken to rectify the systemic deficits that led to errors in only a minority of cases (11.8%).

Conclusion: Preventable errors continue to pose unnecessary risks to patients receiving IV-PCA. Multimodal analgesic regimens and novel PCA systems that reduce human error are needed to prevent errors while preserving the advantages of PCA for the management of acute pain.

Keywords: acute pain; intervention; medication errors; patient-controlled analgesia.

Figure 1.

Schematic for event selection in the MEDMARX database. IV-PCA, intravenous patient-controlled analgesia.

Figure 2.

Distribution of IV-PCA errors reported to MEDMARX based on NCC MERP index classification (n = 1948). The NCC MERP taxonomy categorizes medication errors into nine categories (A–I). Category A, events with the capacity to cause error; Category B, errors that occurred but did not reach the patient; Category C, errors that occurred and reached the patient but did not cause harm; Category D, errors that occurred, reached the patient, and required monitoring to confirm that they resulted in no harm or an intervention to preclude harm; Category E, errors that may have contributed to or resulted in temporary harm and required intervention; Category F, errors that may have contributed to or resulted in temporary harm and required initial or prolonged hospitalization; Category G, errors that may have contributed to or resulted in permanent harm; Category H, errors that required intervention necessary to sustain life; Category I, errors that may have contributed to or resulted in the patient’s death. Per the NCC MERP taxonomy, nonharmful errors include NCC MERP categories A–D; however, in this study, we restricted nonharmful errors to actual nonharmful errors (i.e. NCC MERP categories B–D). IV-PCA, intravenous patient-controlled analgesia; NCC MERP, National Coordinating Council for Medication Error Reporting and Prevention.

Figure 3.

Distribution of factors contributing to actual IV-PCA events in the MEDMARX database (n = 1873). ‘Factors contributing to error’ is a multi-select variable in the MEDMARX database. Thus, single IV-PCA errors can be associated with multiple contributory factors. Within the study period, a total of 2099 contributing factors were identified for 1873 actual IV-PCA-related errors reported to MEDMARX. Events included in the table do not include potential errors (i.e. National Coordinating Council for Medication Error Reporting and Prevention Category A), which are errors that did not occur. IV-PCA, intravenous patient-controlled analgesia.

Figure 4.

Remedial actions taken to prevent the recurrence of IV-PCA events in the MEDMARX database (n = 1948). ‘Action taken’ is a multi-select variable in the MEDMARX database. Thus, single IV-PCA errors can be associated with multiple actions taken to avoid similar errors. A total of 2455 actions were taken to address 1948 actual IV-PCA-related errors reported to MEDMARX. IV-PCA, intravenous patient-controlled analgesia.

Figure 5.

Level of care associated with IV-PCA events that reached patients in the MEDMARX database (n = 1383). The data field for the ‘level of care’ variable is only available for errors that reach patients (i.e. National Coordinating Council for Medication Error Reporting and Prevention categories B–I). The sum of the percentages shown in the diagram is not 100% because some medication error events required more than one level of care (e.g. an event could have warranted administration of both a narcotic antagonist and oxygen). A total of 1688 interventions were initiated for 1383 IV-PCA errors that reached patients. CPR, cardiopulmonary resuscitation; IV-PCA, intravenous patient-controlled analgesia.

Figure 6.

Staff involved with actual IV-PCA events in the MEDMARX database (n = 1873). The data field for ‘personnel associated with an error’ is only available for errors that actually occur. Therefore, potential errors are excluded. Nursing personnel included nurse practitioners/advanced practice nurses, graduate nurses, licensed practical/vocational nurses, registered nurses, travel nurses, and other nonspecific nursing personnel. Pharmacist/dispensing personnel included pharmacists, pharmacy technicians, and other nonspecific pharmacy personnel. Physician and other prescribing personnel included physicians, physician assistants, physician interns, and resident physicians. Others included information technology personnel, material management personnel, physical therapists, students, unit secretaries/clerks, and unlicensed assistive personnel. A total of 91% of nursing personnel-related events were associated with registered nurses; 81% of events associated with pharmacists/dispensing personnel involved pharmacists; and 85% of events associated with physicians and other prescribing personnel involved physicians. IV-PCA, intravenous patient-controlled analgesia.