Reducing Errors During Patient-Controlled Analgesia Therapy Through Failure Mode and Effects Analysis

Despite the reduction in PCA errors since the FMEA was conducted, misprogramming of drug concentration remains a common PCA error. Solutions include safety software for IV infusion pumps, an integral bar-code reader for detecting concentration errors, and interoperability of the software with other hospital information systems. One lesson learned was that an FMEA can lead to resolution of problems beyond the scope of original intent-in this case, the development of a new system for identifying all broken equipment.