Medication errors involving patient-controlled analgesia.
Using the MEDMARX database, this study analyzed nearly 1 million medication error records to compare patient-controlled analgesia (PCA)-related errors with errors that were not associated with PCA. Investigators found that PCA-related errors, which represented 1% of all medication errors, were associated with a higher risk of patient harm. The authors provide a series of strategies for preventing PCA errors and emphasize the need to take a comprehensive approach that addresses the whole process. A past AHRQ WebM&M commentary discussed a case of a PCA overdose and the mechanisms to promote its safe use.