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Device-Related Error in Patient-Controlled Analgesia: Analysis of 82,698 Patients in a Tertiary Hospital

Son, Hyo-Jung MD*; Kim, Sung-Hoon MD, PhD; Ryu, Jeong-Ok RN, MS; Kang, Mi-Ra RN, MS; Kim, Myeong-Hee RN, MS; Suh, Jeong-Hun MD, PhD; Hwang, Jai-Hyun MD, PhD

doi: 10.1213/ANE.0000000000003397
Technology, Computing, and Simulation: Original Clinical Research Report

BACKGROUND: Patient-controlled analgesia (PCA) is one of the most popular and effective methods for managing postoperative pain. Various types of continuous infusion pumps are available for the safe and accurate administration of analgesic drugs. Here we report the causes and clinical outcomes of device-related errors in PCA.

METHODS: Clinical records from January 1, 2011 to December 31, 2014 were collected by acute pain service team nurses in a 2715-bed tertiary hospital. Devices for all types of PCA, including intravenous PCA, epidural PCA, and nerve block PCA, were included for analysis. The following 4 types of infusion pumps were used during the study period: elastomeric balloon infusers, carbon dioxide-driven infusers, semielectronic disposable pumps, and electronic programmable pumps. We categorized PCA device-related errors based on the error mechanism and clinical features.

RESULTS: Among 82,698 surgical patients using PCA, 610 cases (0.74%) were reported as human error, and 155 cases (0.19%) of device-related errors were noted during the 4-year study period. The most common type of device-related error was underflow, which was observed in 47 cases (30.3%). The electronic programmable pump exhibited the high incidence of errors in PCA (70 of 15,052 patients; 0.47%; 95% confidence interval, 0.36–0.59) among the 4 types of devices, and 96 of 152 (63%) patients experienced some type of adverse outcome, ranging from minor symptoms to respiratory arrest.

CONCLUSIONS: The incidence of PCA device-related errors was <0.2% and significantly differed according to the infusion pump type. A total of 63% of patients with PCA device-related errors suffered from adverse clinical outcomes, with no mortality. Recent technological advances may contribute to reducing the incidence and severity of PCA errors. Nonetheless, the results of this study can be used to improve patient safety and ensure quality care.

From the *Charité International Academy, Charite Universitätmedizi, Berlin, Germany

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea

Department of Nursing, Acute Pain Service Team, Asan Medical Center, Seoul, Republic of Korea.

Published ahead of print 14 March 2018.

Accepted for publication March 14, 2018.

Funding: This study was supported by a grant (2017–7013) from Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea. This research was supported by Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Science, ICT and Future Planning (Grant Number: 2016M3A9E8941259).

The authors declare no conflicts of interest.

H.-J. Son and S.-H. Kim contributed equally and share first authorship.

Institutional review board: Asan Medical Center Institutional Review Board, Convergence Innovation Bldg. 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.

Reprints will not be available from the authors.

Address correspondence to Jai-Hyun Hwang, MD, PhD, Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea. Address e-mail to

Copyright © 2018 International Anesthesia Research Society
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