Patient controlled analgesia by proxy.
The Joint Commission. Sentinel Event Alert. December 20, 2004;(33):1-2.
Patient-controlled analgesia (PCA) is a recognized method of controlling pain when administered by credentialed practitioners. However, serious adverse events can result when unauthorized family members, caregivers, or clinicians administer the analgesia for the patient "by proxy." The Joint Commission summarizes the experience of reported PCA incidents and makes recommendations to minimize them.
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Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.
ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.
Shaping systems for better behavioral choices: lessons learned from a fatal medication error.
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
Do Not Disturb!
Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.
Double Dosing, by the Rules
Cohen H. AHRQ WebM&M [serial online]. February/March 2009.
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