Safe patient-controlled analgesia (PCA) use requires proper patient selection, education, assessment, and monitoring (ISMP, 2016). Use the following tips as guidelines to ensure optimal patient comfort and safety when caring for patients receiving PCA.

• Be aware of patient groups who generally are not good candidates for PCA, including infants and very young children, patients with cognitive impairment, patients with conditions for which oversedation poses a significant health risk (e.g., asthma and sleep apnea), and patients who are taking other medications that potentiate opioids.
• All patients should be assessed for level of risk of opioid-induced advancing sedation and respiratory depression; the plan of care and monitoring strategies should be driven by reassessment according to level of risk.
• Caution is required when PCA is used in older adults; patients who are obese or have asthma, sleep apnea or other respiratory disease; patients taking other drugs that potentiate opioids, such as muscle relaxants, antiemetics, and sleeping medications; and patients who are morbidly obese.
• Use standard medical order sets and prefilled syringes with standard drug concentrations.
• Check PCA orders/prescriptions ensuring that they include the medication, the initial loading dose, demand (bolus) dose, lockout interval, and an hourly maximum administration rate. Some prescriptions include a continuous infusion rate.
• Be familiar with the particular PCA infusion device in use at a facility. Use programmable smart infusion pump technology with dose error-reductions systems (ISMP, 2020).
• Ensure that PCA pumps are programmed correctly. Check pump settings at least once every 4 hours. Two nurses should verify PCA programming when initiating infusion or making a change in infusion settings.
• Place warning signs on all PCA pumps that say “For patient use only.”
• Assess pain level, alertness, sedation, pulse oximetry, capnography, and vital signs, including respiratory rate and quality, at least every 4 hours or more often as needed, such as during the first 24 hours of treatment and at night, when nocturnal hypoxia may develop.
• Teach patients and family members/caregivers about the danger of PCA use by anyone other than the patient.

Source: Adapted from Casey, G. (2015). Capnography: Monitoring CO2. Nursing New Zealand, 21(9), 20-24; Cooney, M. F., Czarnecki, M., Dunwoody, C., Eksterowicz, N., Merkel, S., Oakes, L., & Wuhrman, E. (2013). American Society for Pain Management nursing position statement with clinical practice guidelines: Authorized agent controlled analgesia. Pain Management Nursing, 14(3), 176-181; Gorski, L. A., Hadaweay, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., Meyer, B. M., Nickel, B., Rowley, S., Sharpe, E., & Alexander, M. (2021). Infusion therapy standards of practice. Infusion Nurses Society (INS). Journal of Infusion Nursing, 44(1S), S1-S231. https://www.ins1.org/publications/infusion-therapy-standards-of-practice/; Institute for Safe Medication Practices (ISMP). (2016). Acute Care ISMP Medication Safety Alert!^®Worth repeating … Recent PCA by proxy event suggests reassessment of practices that may have fallen by the wayside. https://www.ismp.org/Newsletters/acutecare/showarticle.aspx?id=1149; Institute for Safe Medication Practices (ISMP). (2003; updated 2017). Acute Care ISMP Medication Safety Alert!^®Part II: How to prevent errors. Safety issues with patient-controlled analgesia. http://www.ismp.org/newsletters/acutecare/articles/20030724.asp; Institute for Safe Medication Practices (ISMP). (2013). Acute Care ISMP Medication Safety Alert!^®Fatal PCA adverse events continue to happen … Better patient monitoring is essential to prevent harm. https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=50; and Jungquist, C. R., Quinlan-Cowell, A., Vallerand, A., Carlisle, H. L., Cooney, M., Dempsey, S. J., Dunwoody, D., Maly, A., Meloche, K., Mehyers, A., Sawyer, J., Singh, N., Sullivan, D., Watson, C., & Polomano, R. C. (2020). American Society for Pain Management nursing guidelines on monitoring for opioid-induced advancing sedation and respiratory depression: Revisions. Pain Management Nursing, 21(1), 7-25. https://doi.org/10.1016/j.pmn.2019.06.007; and Lisi, D. M. (2013). Patient-controlled analgesia and the older patient. US Pharmacist, 38(3), HS2-HS6. https://www.uspharmacist.com/article/patient-controlled-analgesia-and-the-older-patient