Medication safety committees regularly review medication errors and near misses. During one such review, the med safety committee at one hospital recognized issues with the way opioids were being ordered via the patient-controlled analgesia (PCA) pumps, including the availability of multiple concentrations of drugs which could be administered in the wrong amount to a patient. Adverse reactions from PCAs can be high-risk and lead to death; however, reconciling these issues was a huge undertaking. To accomplish it, a staff volunteer established a task force that included a pharmacist, surgeon, palliative med physician, pain management physician, clinical nurse specialist, pain resource nurse, and others. Within eight months, they had revamped PCA orders to ensure that patients’ pain not only was going to be appropriately managed, but also managed with appropriate safety precautions in place. One change they implemented was updating PCA machines to provide one-hour maximum doses rather than require four-hour max doses, which was leading to calculation errors. They also created five different order sets for opioids and developed an education roll-out to make providers at all levels aware of changes to the order sets.
