Letter to the Editor: PCA by Proxy

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Letter to the Editor: PCA by Proxy

PA PSRS Patient Saf Advis 2005 Dec;2(4):2.

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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Letter to the Editor:
PCA by Proxy

	THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS
	The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .
	ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.
	The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.