Misprogramming patient-controlled analgesia levels causes dosing errors.

74 P&T® • February 2012 • Vol. 37 No. 2 Errors in initiating PCA infusions can occur at any point in the programming process. By using a limited number of standard concentrations, standardizing order forms, implementing smart PCA pumps with dose error-reduction software (DERS), and requiring an independent double-check of the PCA programming, hospitals can develop effective tools to help reduce PCA dosing errors. However, the risk of a PCA error increases significantly when there are atypical orders, nonstandard concentrations, and unusually high doses. In reports received by the ISMP related to concentrations of PCA infusions, several common findings merit attention: