PCA safety is critical for perioperative nurses. In a
quality study, misprogramming errors accounted for
71% of the adverse events, 15% were related to
human factors causing over- or undermedication, and
9% were related to equipment problems.19 The Joint
Commission and the Institute for Safe Medication
Practices (ISMP) have made significant recommendations
for PCA use for postoperative pain (see Tips for
using PCA safely). Even opioid-tolerant patients can
become oversedated if opioid doses are high enough.
One of the most dangerous adverse effects of PCA
use is respiratory depression.