Background: Patient-controlled analgesia (PCA) is a common and effective means of managing post-operative pain. We sought to identify factors that may lead to critical incidents (CIs) in patient safety when using PCA in our institution.
Methods: An observational study of prospectively collected data of patients who received PCA from 2002 to 2006 was performed. All CIs were documented and analysed by staff members of the acute pain service (APS). Cause analysis of CIs was undertaken to determine if measures can be instituted to prevent recurrence of similar events.
Results: Over eight thousand patients (8,240) received PCA. Twenty-seven CIs were identified. Eighteen were due to programming errors. Other CIs included co-administration of opioids and oversedation.
Conclusion: In our institution, the largest contributory factor to CIs with PCAs was programming error. Strategies to minimize this problem include better education and surveillance.