Implementing independent double checks for patient-controlled analgesia (PCA) pump programming.

153 Background: Pain is the most common symptom experienced by oncology patients. Up to 90% of all patients with advanced cancer experience pain and 50% of those describe their pain as moderate to severe. The patient controlled analgesia (PCA) is commonly used to treat pain on the acute care oncology unit at The Massachusetts General Hospital (MGH). The PCA pump can be programmed incorrectly, resulting in over or under dosing of patients with opiates. Both the Federal Drug Administration (FDA) and the Institute for Safe Medication Practice (ISMP) recommend an independent double check (IDC) be done on error prone processes like the use of high alert medications. An IDC involves two clinicians separately checking (alone and apart from each other, then comparing results) the infusion settings in accordance with the physician’s order. Methods: The nurses on the acute care oncology unit at MGH were surveyed to determine their baseline understanding of an IDC. Training was conducted and a process for documentat...