Please take PCA's seriously

ZASHAGALKA, RN · Jun 9, 2005

Were they your patients, or did you just happen across them (amazing how often that happens - that you get bogged down being the miracle worker for somebody else while your patients . . .)?

What I mean is was it really PCA or NCA (Nurse-controlled Anesthesia) or maybe VCA (visitor), or SCA (non nsg Staff) - you get the point. Theoretically, you gork out before you drop your breathing, yes? Unless your orders are routinely for very high basal rates, this shouldn't be happening unless someone is intervening in unhealthy ways.

But as far as checking --- that's a standard of care!!!! and a vial of narcan should be taped to every PCA pump.

If this has happened 4 times, my guess is that somebody besides patients are pushing that button. So the question is, who is doing it and how do you get them to stop it!!!!!!

~faith

URO-RN · Jun 9, 2005

Were they your patients, or did you just happen across them (amazing how often that happens - that you get bogged down being the miracle worker for somebody else while your patients . . .)?
What I mean is was it really PCA or NCA (Nurse-controlled Anesthesia) or maybe VCA (visitor), or SCA (non nsg Staff) - you get the point. Theoretically, you gork out before you drop your breathing, yes? Unless your orders are routinely for very high basal rates, this shouldn't be happening unless someone is intervening in unhealthy ways.
But as far as checking --- that's a standard of care!!!! and a vial of narcan should be taped to every PCA pump.
If this has happened 4 times, my guess is that somebody besides patients are pushing that button. So the question is, who is doing it and how do you get them to stop it!!!!!!
~faith

I was the one who discovered them. I got report with the " he or she is quite hard to arouse" or the " she/he was sleeping so good I didn't want to wake them up"

Bells and whistles going off in my head , better get down there and check the orders, settings etc...

My guess is that people do not know how to set them up correctly, not following the 5 rights.

No family members were present during my shift. And, no one else was present 1 or 2nd shift.

suzanne4, RN · Jun 9, 2005

If there were four patients on one shift with respiratory rates that low, either your physician is ordering way too high of a basal rate or someone doesn't know how to program the pump to begin with.......perhaps there should be a mnadatory two person chexk of th epump each shift.

pricklypear · Jun 9, 2005

Our protocol for all PCAs is a 2 person check at set-up, and at cassette change, check q4h with a 2 person check every shift. Usually we try to do the 2 person at change of shift - but it can be done anytime.

meownsmile, BSN, RN · Jun 9, 2005

Safest is 2 person check of dosages.

allnurses Guide · Jun 9, 2005

I was the one who discovered them. I got report with the " he or she is quite hard to arouse" or the " she/he was sleeping so good I didn't want to wake them up"
Bells and whistles going off in my head , better get down there and check the orders, settings etc...
My guess is that people do not know how to set them up correctly, not following the 5 rights.
No family members were present during my shift. And, no one else was present 1 or 2nd shift.

Jo Anne are you saying that the settings on the PCA's were wrong and too high?

If that is the case, that is very scary.

We too have the 2 person check -

steph

URO-RN · Jun 10, 2005

Jo Anne are you saying that the settings on the PCA's were wrong and too high?
If that is the case, that is very scary.
We too have the 2 person check -
steph

In one case the settings were indeed wrong. The patient came in from a procedure were they set up the pca. Now, you would think the RN taking care of the patient would do an assessment of the patient and check the settings against the orders and the PCA worksheet, and look at the patient? This was not done.

in the other cases the settings were correct but the patient was way too sleepy and with decreased respirations ...less than 6 and apneic. :uhoh21:

we do have a 2 person check when we set them up, d/c them, increase or decrease the narc etc....

but this is scary.:uhoh21:

Tweety, BSN, RN · Jun 10, 2005

PCAs are serious business. Thanks for the reminder. We do a two-person check at set up and shift change. We check the patient q2h for the first 2 hours and then q4h after that.

talaxandra · Jun 10, 2005

We usually have two people check with set up and cassette change, but it's also hospital policy that the patient's checked every fifteen minutes for an hour after a bolus, and every two hours (RR, SaO2, patient demands and doses delivered) for the duration of the infusion.

I've had a few end-stage renal patients who got narced - always because the surgeons ordered a background rate as well as the PCA - but no problems otherwise.

pricklypear · Jun 10, 2005

Last year we heard about a possible lawsuit involving a death d/t PCA overdose at my institution. We heard lots of different things, but basically all of them would have (or should have) been caught with a 2 person check. If I am recalling correctly, this one started out as a pharmacy error - wrong cassette concentration - that was not caught by the nurse. Either that or the concentration was high (MS 10:1) because of high usage or high doses, but was put in the machine as 1:1. At the time our policy was just a 2 person set up, cassette change, and discard. The FIRST thing I do when I get report on a pt with any PCA is go immediately and check it. If it comes from PACU - I check it against the orders. I just don't trust anybody - and I don't want to be the one to have to say - "well I was going to check it, but just never got around to it."

SmilingBluEyes · Jun 10, 2005

I make it a habit of checking PCA (patient controlled analgesia) and doc that i did so on pain flow chart often.
I discovered 4 count em' 4 patients with respirations of 2 to 4 this week! Narcan given to all....one of them was almost a sentinel event!
anyone else had this happen to them in one week?:uhoh21:

Well where I work, patients on PCA have to be on Sat monitors and two nurses must sign off on the orders and the settings on the machine each and every time it is initiated ---or changed in any way. But narcs have a funny way of "building up" esp among elderly and people with decreased liver/kidney function don't they?

There is nothing that replaces vigilance, to be sure (be it a Sat monitor or dual checks of settings). Your point is so well taken.