JCAHO Sentinel Event Alert: Patient controlled analgesia by proxy
Posted by Clark Venable on 12/21/2004
Sentinel Event Alert Issue 33: Patient controlled analgesia by proxy
" "Patient controlled analgesia (PCA) is an effective and efficient method of controlling pain, and when it is used as prescribed and intended, the risk of oversedation is significantly reduced. However, serious adverse events can result when family members, caregivers or clinicians who are not authorized become involved in administering the analgesia for the patient "by proxy." " "
I had this happen during my training. Healthy patient, uncomplicated anesthetic, uneventful recovery. Three hours after arriving on the floor she had a respiratory arrest. Despite numerous attempts from every quarter to blame my anesthetic (I had used Sufenta, a new synthetic narcotic at that time), it turned out to be the family pressing the PCA button.
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