Device malfunction happens.

After orthopedic surgery several years ago, I awoke in the PACU to find nurses working frantically on one side of my stretcher. Simultaneously, I realized that my leg hurt. A lot. And with another moment’s awareness—awake enough now for my nurse’s brain to begin to kick in—I understood that all of the activity concerned my PCA pump.

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One of the nurses noticed that I was stirring. “Your pump has malfunctioned. We can’t get the replacement to work. A third pump is on the way. I’m so sorry!”

The scramble for a replacement, and then another, probably lasted less than five minutes, but it was a pretty wild ride. My deep breathing in an attempt to control the pain gave me something to focus on, but it was a pretty weak effort up against bone pain in the immediate post-op period. I’m grateful that my nurses—there were at least three involved at that point—regarded the pump failure as an emergency.

But operator errors are more common.

Needless to say, then, I was particularly interested in a new study that appears in this month’s AJN. In “Errors in Postoperative Administration of Intravenous Patient-Controlled Analgesia: A Retrospective Study,” Yoonyoung Lee and colleagues examined the records of all patients who received IV patient-controlled analgesia during a three-year period at their academic medical center in South Korea.

While overall, errors occurred in less than 1% of cases, they found that operator errors were the most frequent type of error, followed by device malfunction. In discussing their findings, our authors highlighted the analysis of another team of researchers, who observed the following:

“…the influence of human factors on PCA errors was more evident than on non-PCA errors, suggesting that the PCA process is heavily dependent on individuals executing sequential tasks successfully.”

Active monitoring is crucial.

With today’s “smart pumps,” we almost expect the machine to do everything but start the IV. In the midst of a busy shift, it’s natural to rely on the pumps to “take over” once we’ve threaded the tubing and input our parameters. The work of Lee and colleagues reminds us that we should be actively monitoring pump activity, just as we would follow up after we’ve delegated a task to an individual. Read about their findings and recommendations in this month’s AJN.