ReviewDrug safety2009
Patient-controlled analgesia-related medication errors in the postoperative period: causes and prevention.
Review in Drug safety, 2009. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 16 papers, 1 of them a synthesis that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
16 citing papers in PubMed, 1 synthesis or guideline pooled it.
- [Pediatric perioperative systemic pain therapy: Austrian interdisciplinary recommendations on pediatric perioperative pain management].Schmerz (Berlin, Germany) · 2014Guideline
- Patient-Controlled Analgesia in ICU: A Scoping Review.Journal of personalized medicine · 2026Review
- Sublingual sufentanil for patient-controlled analgesia during labor induction for pregnancy termination: an effective and well-tolerated approach.Journal of anesthesia, analgesia and critical care · 2024Article
- Article
- [Critical incidents in acute pain management-A risk analysis of CIRS reports].Der Anaesthesist · 2022Article
- Factors associated with success and failure of patient-controlled oral analgesia after total hip and knee arthroplasty: a historical comparative cohort study.Canadian journal of anaesthesia = Journal canadien d'anesthesie · 2021Article
- A preliminary assessment of vital-signs-integrated patient-assisted intravenous opioid analgesia (VPIA) for postsurgical pain.BMC anesthesiology · 2020Article
- Impact of Patient-Controlled Analgesia (PCA) Smart Pump-Electronic Health Record (EHR) Interoperability with Auto-Documentation on Chart Completion in a Community Hospital Setting.Pain and therapy · 2019Article
- Medication errors involving intravenous patient-controlled analgesia: results from the 2005-2015 MEDMARX database.Therapeutic advances in drug safety · 2018Article
- Sublingual sufentanil tablet system Zalviso® for postoperative analgesia after knee replacement in fast track surgery: a pilot observational study.Journal of experimental orthopaedics · 2018Article
- Comparison of fentanyl iontophoretic transdermal system and routine care with morphine intravenous patient-controlled analgesia in the management of early postoperative mobilisation: results from a randomised study.British journal of pain · 2016Article
- Evolution of Patient-Controlled Analgesia: From Intravenous to Sublingual Treatment.Hospital pharmacy · 2016Article
- Acute Pain Medicine in the United States: A Status Report.Pain medicine (Malden, Mass.) · 2015Article
- Safeguarding the process of drug administration with an emphasis on electronic support tools.British journal of clinical pharmacology · 2013Article
- Drug overdose due to malfunction of a patient-controlled analgesia machine -A case report-.Korean journal of anesthesiology · 2013Article
- Hypertension associated with neurocognitive performance among persons with type 2 diabetes: a brief report.Mental health in family medicine · 2011Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
5 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
Patient-controlled analgesia (PCA) is a common and effective means of managing postoperative pain. Unfortunately, the complex processes and equipment associated with the setup, programming and administration of intravenous or epidural PCA have allowed it to become a significant source of preventable medication errors. These errors can be classified into two major categories: human (operator) errors and equipment errors (malfunctions). Such errors are potentially harmful to patients, time-consuming for hospital staff and costly for healthcare providers. The objective of this article is to describe PCA medication errors and examine systems and modalities that may help reduce the incidence of system-related errors. Data from the US FDA's Manufacturer and User Facility Device Experience (MAUDE) database indicate that 6.5% of intravenous PCA-related events were due to operator error. Most (81%) of these errors were due to pump misprogramming, of which almost half were associated with patient harm; 76.4% of adverse events were attributed to device malfunction (e.g. due to frayed wires or a crack in the drug cartridge), although only 0.5% of these were associated with harm to patients. In a report based on data from MEDMARX, a voluntary database that captures reports on medication errors, 7.9% of the PCA-related errors captured over a 5-year period were described as causing harm to patients. Technological advances, such as improved PCA pump designs based on ergonomic and cognitive engineering principles, the use of barcode technology and other 'smart pump' safety features, and new postoperative pain management modalities, may play a significant role in reducing the future incidence and severity of PCA medication errors.
Indexed as
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.