Case Study: Medication Diversion Through Intravenous Patient Controlled Analgesia (IV PCA) Manipulationion

Abstract

The diversion of opioid medications is a concern in the hospital setting. The main focus of diversion in institutions is healthcare providers diverting medications. There are instances in the literature of nurses who have diverted Intravenous Patient Controlled Analgesia medications and reinstated the removed volume with saline infected with bacteria. These cases were investigated because a cluster of patients with bacteremia occurred.

Patient diversions have been documented as case reports primarily. The manipulations have occurred with opening the lock box with a paper clip or opening if the lock box was loaded incorrectly

reported diversions occurring from manipulating the programming of the pump or stealing the IVPCA key

The purpose of this case study was to determine how a patient could divert medication from an IV PCA using the simulation lab arm. The arm is pressurized to simulate blood flow using red colored solution and green food dye colored the IVPCA fluid.

The second trial provided a mechanism to obtain more medication from the system when the needled syringe was placed proximal to the IVPCA machine. The opioid medication was siphoned after the Patient Controlled Analgesia button was pressed and pulling back of the plunger of the syringe while administering the bolus. The patient was able to divert 2ml (2mg) from the tubing and administer instead of the .2mg with each PCA bolus dose. A small pin hole in the tubing was the only indication medication was removed in a manner other than PCA bolus dose.

Diversion of medications in the hospital is a concern for patient safety. Patients manipulating programming of pumps or compromising the closed IVPCA system physically needs to be prevented. The hope of this clinical presentation is to provide clinicians with the knowledge of this possible medication diversion method in the hospital setting.