Chicago, IL (PRWEB) January 28, 2013
Centers for Medicare & Medicaid Services (CMS) is currently considering a proposed quality measure that requires "appropriate monitoring of patients receiving PCA patient-controlled analgesia." This measure seeks to address the high number of errors that occur with PCA, which unfortunately research shows happens all too frequently.
The Pennsylvania Patient Safety Authority recently released its analysis of medication errors and adverse drug reactions involving intravenous fentaNYL that were reported to them.
Researchers found 2,319 events between June 2004 to March 2012. That's almost 25 events per month or about one every day. Although one error a day may seem high, their analysis is confined to reports made to the Pennsylvania Patient Safety Authority and only include fentaNYL, a potent, synthetic narcotic analgesic with a rapid onset and short duration of action.
However, CMS’ proposed measure falls short of recommendations by major healthcare organizations.
Frank Federico, a member of the Patient Safety Advisory Group at The Joint Commission, and executive director at the Institute for Healthcare Improvement, explains further, “As currently written, the CMS proposed quality measure runs the risk of looking like it is protecting patients, while in reality not going far enough. Although nurse spot checks on patients are advisable, pulse oximetry and capnography are essential risk prevention tools in any pain management plan. The proposed CMS quality measure should include continuous electronic monitoring."
Robert Stoelting, MD, president of the Anesthesia Patient Safety Foundation, agrees with this assessment. He says, "the conclusions and recommendations of APSF are that intermittent 'spot checks' of oxygenation (pulse oximetry) and ventilation (nursing assessment) are not adequate for reliably recognizing clinically significant evolving drug-induced respiratory depression in the postoperative period. For the CMS measure to better ensure patient safety, APSF recommends that monitoring be continuous and not intermittent, and that continuous electronic monitoring with both pulse oximetry for oxygenation and capnography for the adequacy of ventilation be considered for all patients."
For a complete copy of the article recently published in Becker’s Clinical Quality and Infection Control, please see: