2015 Finalist: University of Colorado Hospital

Aurora, CO
Thinking Outside the Pump: Strategies for Improving the Safety of Patient-Controlled Analgesia

Patient-controlled analgesia (PCA) is an effective method for controlling pain when used appropriately. Opiate narcotics commonly used in PCA are considered to be high-alert medications and therefore bear a heightened risk of causing significant patient harm when they are used in error.

Review of University of Colorado Hospital aggregate patient occurrence data through our hospital-wide Medication Safety Steering Committee (MSSC) identified a significant patient safety concern with this low-volume/high-risk therapy. Over an 18-month period, 70 PCA-related medication errors were reported. Twenty-six percent of the events resulted in temporary harm and/or required intervention to prevent harm. The majority of events involved wrong rate of administration errors and pump programming errors related to incorrect drug concentration selection. Review of data by multidisciplinary committees identified that the major contributing factors to these patient occurrences were our electronic health record (EHR) build, inconsistent practices related to independent double checks, outdated technology and nonstandardized drug concentrations.

Pharmacist Leadership
Since 2000, University of Colorado Hospital (UCH) has employed a full-time pharmacist as a Medication Safety Coordinator (MSC) who also serves as Chair of the MSSC. One of the charges of this committee is to identify occurrence trends and apply process improvement (PI) methods to address system changes. The MSC managed the overall project from identification of the problem through implementation and assessment of institutional impact and was responsible for tracking data throughout the process and presenting to hospital staff and leadership.

After completing a failure modes-and-effects analysis to identify factors contributing to error, a pharmacy-led interprofessional team developed comprehensive solutions to address significant areas of risk. The project utilized a two-phase approach, spanning over 20 months, to address patient safety concerns throughout the medication-use process. Improving access to information, standardizing practices and medication concentrations, revising order sets and developing a drug library, improving drug preparation and workflow, providing comprehensive staff training, and establishing a long-term plan for continuous quality improvement were the areas targeted for improving safety.

Following Phase I, which included EHR optimization, standardization of independent double checks and selecting new technology interim outcomes data noted:
  • Forty-seven percent reduction in the total number of reported errors reaching the patient and a 100-percent reduction in errors causing harm.
  • Capital cost-savings were realized following contract negotiations related to electing new PCA technology for implementation across the health system.
Following Phase II, which included hiring dedicated full-time employees to manage infusion device implementation and maintenance, standardizing PCA medication concentrations, modifying and creating new orders sets, conducting staff training and implementing the new technology, outcomes included:
  • An additional 30-percent reduction in total number of reported errors.
  • A 52-percent reduction in wrong concentration errors, and an estimated salary cost savings of more than $26,000 through the utilization of a train-the-trainer model.
At 15 months post-completion of Phase II, this comprehensive safety initiative continues to demonstrate a sustained improvement in patient safety with:
  • A 67-percent reduction in patient occurrences.
  • A 70-percent reduction in the number of events requiring treatment or intervention.
  • Additionally, more than $1.4 million in potential avoided costs from severe harm-averted events was documented in the 16 months following smart pump technology implementation.
Published data supports that smart pump technologies aid in delivering safer patient care, but it is not enough to purchase these pumps and hope that their safety features alone will improve patient outcomes. Safe use of PCA depends on a comprehensive program that employs key safety principles throughout each step of the medication-use process. The interprofessional team utilized an innovative multiphase strategy to design an approach to care that ultimately reduced medication errors and patient harm related to PCA.

Interprofessional Team
Sondra May, Pharm.D.
Sylvia Park, R.N., B.S.N.
Kristen Case, M.S., CNRN
Angela Dangler, Pharm.D., BCPS
Deb Bonnes, R.N., M.S.
Ken Ferretti, M.B.A., M.P.M., Pharm.D.
Fred Jaramillo, C.B.E.T.
Christine Steckline, Pharm.D.
Alan Oldland, R.Ph.
Shannon Davis, CPhT
Jamie Poust, Pharm.D., BCOP
Clark Lyda, Pharm.D.
Robert Montgomery, N.D., R.N.-BC, ACNS-BC
Jean Youngwerth, M.D.
Michelle Ballou, B.S.N.
Glenn Schmidt
David Rowley
Joseph Springfield
Robert Gutho
Quentin Keith Roberts
Michael Bynum