ISMP Issues Pain Pump Safety Warning

Anesthesia

By: OSD Staff

Published: 8/5/2009

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Improper management of post-op pain relief devices poses serious risk to patients.


The Institute for Safe Medication Practices has issued an advisory on the safe handling and use of elastomeric pain pumps, such as the ON-Q PainBuster system, in response to reports it???s received about problems with the devices.

If used correctly, pain pumps can offer continuous, post-op pain relief for up to 5 days after surgery, notes the ISMP. But hospitals and surgery centers have reported several process problems with the pumps that could compromise patient safety, including:

  • lack of staff and patient education about their use;

  • lack of pharmacy involvement in ordering, preparing and filling the pumps;

  • insufficient labeling and hand-off communication during pump administration in the OR;

  • mixing with medications other than local anesthetics, or use of concomitant analgesics;

  • varying infusion rates and concentrations;

  • lack of documentation and monitoring of pain pump drug therapy on the patient???s medication administration record; and

  • continued use after the recommended 5 days.

    The ISMP advisory includes a table outlining safe practices for surgical facilities to follow on pain pump preparation, prescribing, catheter placement and pump setup, dispensing pumps and medication, and nurse and patient education about their use.

    For more on how to avoid complications with post-op pain pumps, see "The Keys to Pain Pump Success."

    —Irene Tsikitas

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