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Reporting a Medication Error

Don't Push the Pain Pump Button for Others

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Republished June 26, 2024

The story: A pain relief system known as patient-controlled analgesia (PCA) allows a patient to take pain medicine without having to call a nurse. It is used most often in the hospital. The concept is simple: A pump containing pain medicine is attached to your intravenous line (the tube that goes into your vein).

When you feel pain, you push the button on the pump and you receive a dose of medicine. But this system must be controlled only by the patient, not by others. Patients have died when friends or family members pushed the button because they thought their loved one was in pain.

One was a teenager who died after receiving too much Dilaudid (hydromorphone). He was given the PCA device after surgery. His mother pushed the button for him several times while he was sleeping. She believed she was making her son more comfortable.

The rest of the story: With PCA, the patient himself provides a measure of safety. If the patient is too sleepy, he will not push the button to give more medicine. This built-in safety feature helps prevent patients from receiving too much. But if other people push the button for him, the device may deliver unneeded medicine that can cause a tragic overdose.

Lessons learned: PCA gives you access to your pain medicine when you need it, an important step forward in pain control. However, make sure that family and friends know not to push the button for you or anyone who is receiving PCA.

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