Patient Safety

Controlling Pain with PCA

Patient-Controlled Analsegia (PCA) is a method of pain control in which the patient can administer his own pain medication when needed. The patient is given a button to disperse medicine when he is experiencing pain. If the patient continues to have pain after pushing the button, he can tell the physician or respiratory therapist. The dosage is safely timed while the patient is connected to the machine so that he cannot give himself more medication then the doctor thinks is right.

Reducing Risk

A common risk when a patient is attached to a PCA pump is that the patient can go into a state of respiratory depression. This means that the pain medication has caused the patient’s breathing to slow down. If this occurs, the patient becomes unable to exhale properly, and carbon dioxide (CO2) will build up in his lungs.

How Capnography Helps

Capnography is a non-invasive monitor that continuously measures the level of carbon dioxide (CO2) in the patient’s exhaled breath. This type of monitoring is the most effective to catch respiratory depression

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Patient Incidents

“Hospitals need to address the causes of PCA errors now. Appropriate education of patients, family members, and hospital staff is key.”
— Michael Cohen, President, Institute for Safe Medication Practices

Leah Coufal, healthy 11-year old girl
Not monitored after elective surgery

Louise Batz, grandmother
Died after elective knee surgery

Justin Micalizzi, healthy 11-year old boy
Died after surgery to incise and drain a swollen ankle

Matt Whitman, retired state trooper
“By the grace of God, an observant nurse who just happened to walk by my room when I stopped breathing, called a Code Blue, and that ultimately saved my life.”

Where to Go from Here

Adverse events and patient deaths are preventable, so let’s stop it from happening!

The technology and know-how exist to prevent PCA-related incidents and deaths. Periodic caregiver checks and pulse oximetry detect but do not prevent all error. Capnography is the only successful way to assess adequacy of ventilation.

Hospital protocols should call for continuous electronically monitoring of all their patients using PCA pumps with oximetry and capnography to eliminate the possibility of respiratory depression as a cause of death.

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Hospitals That Monitor

See which leading hospitals are implementing PCA monitoring

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Granger Indiana 46530


This campaign was researched and created by University of Notre Dame Graphic Design students in the Fall of 2012.