First National Survey of Patient-Controlled Analgesia Hospital Practices Reveals Patient Safety Concerns and Role of Continuous Electronic Monitoring

Oct 16, 2013, 09:15 ET from Physician-Patient Alliance for Health & Safety (PPAHS)

CHICAGO, Oct. 16, 2013 /PRNewswire/ -- The Physician-Patient Alliance for Health & Safety (PPAHS) today announced the release of major patient safety findings of the first national survey of patient-controlled analgesia (PCA) practices presented at the recent Society of Anesthesia and Sleep Medicine (SASM) 3rd Annual Conference held October 10-11, 2013.

According to reports made to the Food and Drug Administration between 2005 and 2009, more than 56,000 adverse events and 700 patient deaths were linked to PCA pumps. One out of 378 post-surgical patients were harmed or died from errors related to the patient-controlled pumps that help relieve pain after surgical procedures, such as knee or abdominal surgery.

"A national survey of United States hospitals regarding PCA administration has never been conducted," says Michael Wong, JD, founder and executive director of the Physician-Patient Alliance.

Those involved with the analysis survey and preparation of the survey report were Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), Anuj Mabuyi, PhD (Assistant Professor Department of Mathematics, Northeastern Illinois University), and Beverly Gonzalez, ScM (Biostatistician, Johns Hopkins Bloomberg School of Public Health).

On the negative side, the survey shows a huge cause for concern for patient safety, as there is a great lack of consistency in safety procedures being followed by hospitals across the country. "This most likely accounts for a large proportion of adverse events and deaths associated with PCA use," says Mr. Wong.

On the positive side, survey findings also show that adverse events have been averted and/or costs and expenses reduced by hospitals that are continuously monitoring their patients with pulse oximetry and/or capnography. This demonstrates the critical importance of using continuous monitoring as a technological safety nets for patients. As well, it also points to a way hospitals may reduce their costs and expenses.

"However, when we looked at the type of smart pump being used at the facilities reporting a decline in adverse events or a return on investment, there was a significant correlation with those using smart pumps with integrated end tidal monitoring," says Mr Wong. "Those using smart pumps with integrated end tidal monitoring were almost three times more likely to have had a reduction in adverse events or a return on investment when measured against costs and expenses (including litigation costs) that might have been incurred."

For a pdf handout of the poster presentation made at SASM annual conference can be found at

PPAHS plans to release a full copy of the PCA survey report in the next few weeks.


The Physician-Patient Alliance for Health & Safety (PPAHS) is an advocacy group devoted to improving patient health and safety. PPAHS supporters include physicians, patients, individuals, and organizations. For more information can be found at

PPAHS recently released a concise checklist that reminds caregivers of the essential steps needed to be taken to initiate Patient-Controlled Analgesia (PCA) with a patient and to continue to assess that patient's use of PCA. For a free download of the PCA safety checklist, please visit

PPAHS is also developing a checklist targeting venous thromboembolism (commonly referred to as blood clots) for women having cesarean and vaginal delivery, and the extension of prophylaxis post discharge; for more on this initiative, please see

SOURCE Physician-Patient Alliance for Health & Safety (PPAHS)