Patient Safety Alert 6: RCA Information Exchange – PCA Pump Alarm Update (PDF)
The AMC PSO performed a review of safety issues involving ambulatory pumps used to administer patient controlled analgesia (PCA). Recurrent “air in line alarms” shortly after set up has been identified as one issue of concern.
Updated Safety Strategies
Preliminary discussions with the manufacturer indicated that a potential cause for the alarm might be pinching of the cassette pump tube between the pump chassis and the cassette.

Library of All AMC PSO Patient Safety Alerts
For even more patient safety alert material, please review our series of AMC PSO Patient Safety Alerts to understand the variety of topics covered by our members. AMC PSO makes patient safety learnings available to the public as part of CRICO’s ongoing commitment towards improving patient safety across the continuum of care.
