PA PSRS Patient Saf Advis 2005 Dec;2(4):2.
Letter to the Editor: PCA by Proxy
Anesthesiology, Nursing
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We received the following letter after our article “PCA by Proxy—An Over­dose of Care” appeared in the June 2005 Advisory:

When the Sentinel Event Alert regarding PCA by proxy was issued by JCAHO in December 2004, Abington Memorial Hospital evaluated the safety measures we had in place and looked at additional oppor­tunities to prevent a similar event from occurring within our facility. We found that we had several safety measures already established and initiated others.

As a direct reminder to the patient and his/her visitors, we applied stickers that read “Patient Use Only” to all patient administration pen­dants. We also incorporated the message that only the patient is to press the PCA button to administer pain medication into our PCA Patient Education tool. Throughout the education tool, it is empha­sized that only the patient should press the button for administration of pain medication, and the word “you” is bolded. 

The nursing policy for PCA administration clearly indicates that only the patient should press the PCA button, and there are clear guide­lines for when the nurse is able to administer a “proxy” dose. Lastly, we attached an index-sized card to the pumps reinforcing the mes­sage to patients and visitors that only the patient is to use the PCA button for pain medication administration. 

Cindy Koeneman, RN
Abington Memorial Hospital
Patient Safety Coordinator

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