RISK OF ERRORS SHOULD BE LOW


The risk of errors varies between treatment modalities. Analgesia-related errors include:

 

  1. Communication errors
     
    •  Communication errors can be avoided by effective team work and communication.
       
  2. IV PCA errors
     
    • About 80% of IV PCA errors are device-related.1
       
    • The errors can result in: analgesic gaps, requirement for opioid antagonist, sedation, dizziness, respiratory depression, respiratory arrest or even coma and death.
       
    • Improved guidelines, comprehensive staff training and safer technologies can all contribute to reducing errors.2,3
       
  3. Medication errors, e.g. in the use of opioids
     
    • Opioid medication errors include improper dose/quantity, omission, prescribing errors, unauthorised/wrong drug, extra dose, wrong administration technique or incorrectly prepared drug.4
       
    • 5.9% of opioid medication errors result in moderate to severe patient harm.5
       
    • Staff training and written protocols may help to reduce the incidence of errors. 4,6

 

References

1 Hankin CS et al. Adverse events involving intravenous patient-controlled analgesia. Am J Health-Syst Pharm. 2007; 64: 1492-9.
2 Paul JE et al. Impact of a comprehensive safety initiative on patient-controlled analgesia errors. Anesthesiology. 2010; 113: 1427-32.
3 Schein JR et al. Patient-controlled analgesia-related medication errors in the postoperative period. Drug Safety. 2009; 32: 549-59.
4 Dy SM et al. Medication errors with opioids: results from a national reporting system. J Opioid Manag. 2007; 3: 189-94.
5 NHS National Patient Safety Agency. Reducing dosing errors with opioid medicines. July 2008.
6Benhamou D et al. Postoperative analgesic therapy observational survey (PATHOS): A practice pattern study in 7 central/southern European countries. Pain. 2008; 136: 134-41.