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University of Colorado Ilospital Policy and Pp+.re* Patient Controlled Analgesia (PCA): Adult anQ Pediatrlc\,
Related Policy and Procedures:
Central Venous Lines Peripheral Venous Lines Medication Management Pain Management: Adult and Pediatric Pyxis Medication System Controlled Medication Management Epidural and Intrathecal Infusion Analgesia Equipment Failure and Safety Hazard Reporting

*f'

_/ -

*Xo

-_

Approved

by:

Professional Practice Policy and Procedure Committee Effective: 6/99

Revised: 1/11 Revissd: 3ll4j

Inrvcrted new

il[is fqrpolicyl

Description:

This policy and procedure describes the process for patients to receive safe and atient controlled analgesics analgesia (PCA) infu sion deviocsrqrnge-lsadulg. [h e goal s are : L To provide procedures for initiating, checking, and verifying PCA orders, 2. To provide procedures for PCA opioid use, dosage, and safe practice. 3. To standardize monitoring parameters. 4. To standardize documentation.

effectivi administratiorr of parenteral opioid

Accountability: 1. A physician or allied

health provider must order PCA infusions. Initial orders must be

*ritt"n

ling

a.n

El?lc-etdpr sql,-$fiich inclLrdei

standard concentrations, dose settings and monitoring parameters.-fiubseg$en*'"P6d-$rd'eft ordered in addition to a PCA should be authorized by the physician

2, Opioids or sedatives
3.

4.

service that wrote the PCA orders before they are administered. This is required to prevent excessive sedation from other systemic controlled substances or sedatives. New PCA orders will be written when a patient is transferred to another nursing unit (e.g., transfer in/out of ICU). PCA orders will be rewritten or renewed every 14 days. All health care professionals (physicians, nurses, pharmacists) are accountable for verifying and checking PCA orders for accuracy, Physicians and nurses are accountable for checking

the intravenous (IV) site for patency prior to starting an infusion and may initiate PCA pumps only if appropriately instructed, PACU nurses are accountable for initiating PCA

5.

infusions for postoperative patients prior to sending the patient to another nursing unit. Pharmacists are accountable for supplying opioids for PCA in pre-mixed syringes/bags. Any drug wastage from the PCA pump must be witnessed and appropriately independently documented by two nurses, physicians and/or pharmacists as per the UCH Controlled Medication Management policy.

c15841

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Patient Controlled Analgesia @CA): Adult and Pediatric

Definitions:

Bolus or Loading Dose: One time dose of medication that may be given at the start of a PCA infusion, or that riay be given as an additional dose to zupplement PCA therapy. Basal or Continuous Rate: The amount of medication automatically infused per hour'

@'PCAP"9qp;]hepm9'yp19fmedi'c9{91infuq9dwh-e111hgpa1igtt.!
presses the control button. dose and the

B.r.Al+116] t4rxt

Lockout or Delay Time: Period of time that must pass between the completion of one PCA Patient Controlled Analgesia (PCA): Delivery of opioids via an electronic pump which
enables the patient to self-administer small doses (usually IV) at frequent intervals, maintaining blood levels of opioids within an effective range, pCA by Proxy: Unauthorized administration of a PCA dose by anyone other than the patient, i.e., family members, caregivers, clinicians, This form of PCA therapy is not allowed at UCH'

initiation ofthe next,

Table of Contents:

2. PCA Opioid Use, Dosage, and Safe Practice 3. Initiation of PCA TheraPY 4. Monitoring 5. Documentation 6. Education 7. Referonces
Policies and Procedures:

Verification of Orders

1. Verification

of Orders
are administering PCA must verify and check PCA orders The
9.1

All heatth care professionals who

for accuracy and ensure that the patient is not allergic to the prescribed drug.
mgdnl)
.

physician's order should contain the following: A. Name and stre*lgtllhsaggntraligtubf &ug (pg/rnl B. Bolus or loading dose (mg or mcg) C, Basal or continuous rate (mgAr or mcg/hr)

goto6e

!{tS$I

etrryg! trcr ldads'r'saE

E. F.

Lockout or delay time (minutes) Monitoring instructions (respiratory rate, sedation, pain intensity, etc')

2.

PCA Opioid Use, Dosage, and Safe Practice

A.

Suitable candidates for PCA include patients with pain who are mentally alert and able to comprehend and comply with instructions and procedures regarding its use. Patients who may not be suitable candidates include: infants and young children, patients with altered

mental status (confusion, agitation, restlessness), patients with decreased level of consciousness, patients who are not psychologically stable, and patients without

B.

intellectual capacity to understand and operate the PCA' Demand Ooseipce) only is the safest rnode fpis[tini{rriye'pd'e$ft]and i9 no-rmplly used initially in the majority of patients with post-surgical or acute pain'

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Patient Controlled Analgesia (PCA): Adult and Pediatric

C.

A basal infusion dose is normally only used in the opioidtolerant patient,

as needed.

Opioid-tolerant is defined as those patients who have been receiving opioids regularly for approximately 7 days or more. A basal dose should not be increased more frequently than every 10-12 hours to allow steady state to be reached and the full effects ofthe dose
increase to felt/observed.

To reduce the risk of opioid-induced respiratory depression, monitoring of oxygenation by continuous pulse oximetry may be required by provider's order. Risk factors for opioid-induced respiratory depression have been recognized in the literature and are noted in the box below. These risk factors should be considered when determining who might benefit from the use of mechanical monitoring via continuous pulse oximetry' Having a risk factor does not automatically require continuous pulse oximetry; the severity of the factor(s) and the patient's condition should guide the decision to use continuous pulse oximetry. It should be noted that continuous pulse oximetry may be automatically required by specific nursing unit protocols.
Risk Factors for OpioidJnduced Respiratory Depression
Continuous Pulse

Oximetry

2. 3. 4. 5. 6. 7.

1.

Use of a basal infusion dose in the non opioid-tolerant patient. Obstructive Sleep Apnea (OSA), or suspected of having OSA. Pulmonary disease or dysfunction (e.g., COPD). Obesity, BMI > 35 kg/m2 Greater thar.64 years old. Receiving other opioid or sedative drugs in addition to PCA. Imoaired renal or hepatic function.

The severity ofthese factor(s) and the patient's condition should guide
the decision to use continuous pulse

oximetry

E. PCA by Proxy is not allowed.

Unauthorized administration of a PCA doselby anyone other than the patient, i.e., family members, caregivers, clinicians, can lead to over sedation, respiratory depression, and even death. Ifa patient is unable to self-administer their PCA dose, notify the physician service managing the PCA. Consideration should be given to discontinuing PCA therapy and utilizing altemate therapy such as IV push. Under no circumstances should anyone else push the PCA button for the patient. If the patient asks a health care provider to push their PCA button for them (e.g., patient cannot reach button), the provider should provide the button to the patient to administer their own dose.

PD

g7^ War* tv tl:"nrnrn;f ran

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"'

b)lttS
nmu*ittr[*pglt.1fr t ]rblq rs{neysd.petr rn*t'tablo;''r''
"

rrilsris

Team Recornmeudatiom to avoid conflrgion with

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+-FAS

ki*iel

ieitiel
{fi6*$

In*ti*e

f+erpH*e-(-l-$eAn"B o**eryhene{O'?+r'Wml)

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R-t+eom**nded

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0,?-04*ag
+gaS*moe

8--t*iifi.

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e+-r1lS

k*flr
8--rlri+h

een+ar*y++l+$*egd)

cl 5841 I

Page 3

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Patient Controlled Analgesia (PCA): Adult and Pediatric

(i,1"...

. ......_USuAl range of PCA dosages for acute/postoperative

Opioid
Usual

pain in opioid naive adults:

Usual Incremental Range Usual

Usual
Basal Range

(Concentration) Morphine (IJrn/.]) Hydromorphone (0*1 mg/ml) Fentanyl ({"[0 mcg/ml)

Loading Range

Lockout

044$93:I
m8 *S30,50 mcg

*&5:*,s3.,

0:1.q!gt!!
0-0,2 mg/hr 0-25 mcglhx

0,51],mg 0.1s,$0''6r.ng 10-50 mcd

a!"r-gve

8-10 min 8-10 min 6-10 min

gtihn EinttlUl0li
EPIC

upaaleu to *nac! esnerl

rocommdatim
Centered

Note: No _limitation.iu dosinn is imnlied by-tle

Jilblq.

Formatted:

jBasal rate iE not routilrely rpqoq.mended in clpioid naive patients. Horvever" if a qi19ti9 9f c9gi1}9uq Qaqa!) (9s.-e-.19 incremental (PCA) dose should remain approximately 1:2. *"11-_Optimal opioid analgesic dose varies widely even among opioid-naiVe patients: adjust dosing based on patient response. &i" For pediatric patients, the decision to use PCA will be based on their individual needs and abilities. Pediatric dosage will be by weight until l2 years ofage/or 50 kg. The physician service managing the PCA must obtain consent from parent/legal guardian for pediatric patients under eighteen (18) years. Any special assessment, monitoring, or dose titration parameters should be established by the physician service managing the PCA when the infusion is ordered. bnq*t iritg,ip:qr.{!*rg

{1.(1.

forr:es;rlptaritr@i &

,Go-l$mgnt nfiro*eopo*tOE Ra,mt*d fgar rs *lirig Tsani thso is ffimtly rc pdiatric mtsy built into fte PCA prmp or EPIC's order sets.

ttirtf:r

qeteid

{6

U.tusl

U*rq*
gsga}e;*rl'8rb

isn}

&6d*ru
&wgq
30-riroglkg S+*e#t+g +-n+e#l*g

U6s"l {fiqrgeils{al *fl&ge

U*sd t
{i*le"min; &4&n*in
6*+$-n+in

{?rrS t\
oLLl &otu H s

Molph.iue-(1-lr*gl:rr+l)

0-30-rqeelk#hr
0-5-tll$.S1li#hr

+&30$eg&g

Iie"tnsi+{+0-mc$rm4)

U-+-n+edk#hr

++meslkt +'Z+-segrl

J.

PCA dosage ranges in the opioid-tolerant patient can be much higher than those listed the above tables, The Acute Pain Service (APS) 303-26 6-6493 may be consulted
determine appropriate PCA dosages in this population.

in -- ro* : M of ,^.

((.(YWL #ots ?
patt
^nl

SWo*Lc{

l)'L

CA^..L

I,,l(.

In addilion to opioitl narve and onioid tolcrant UCH has a third category

syi{urte$lqr'$miied'hng$e{iaedit*i{inj U..$"r.rgj}n$"-udar $sJ i:s$uttfi rr]-an p]t1s:ralls, qa.irsr]Lt tq tlre llAlliati"vq Car"g IeAm: this c-ensult j,s r:ecluired to use this ofile,r set. &1,!" _Nurses may adjust pump qettings within ranges and give bolus doses as ordered, iA re*bntl RN v*ritleati*rt i,. NOT rerluirsd fbt lirllJs-dCIp*s"l
Page 4

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Dirgqq*trtttrxpl
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Patient Controlled Analgesia (PCA): Adult and Pediatric

Fi"M, ..-..................Two RNs must independently verify drug, volumen concentration, and rate including all pump settings against the orders when: 1. lnitiating the PCA infusion t 2. Accepting patient from another floor 3, Changing shift (with off-going RN to oncoming RN) 4. Changing any settings or changing drug {.},X--"--_Meperidine (Demerol) is not available for PCA due to accumulation of an active metabolite, normeperidine, which can cause seizures and tremors, {4g1.*- - *."-Morphine should be used with caution in patients with renal insufficiency due to its more potent active metabolite, morphine-6-glucuronide (M6G), M6G has decreased clearance and increased elimination halfJife in these patients. Q,l). -PCA opioids may be administered via,a subcutaneous{$S-intrsiott--h .ryggl"?"l circumstances when IV qqgegs !s not possible.

Palliative Care Tpaln consult is recommsnded when using tbe su,bcutarreous PCA oldsr ser- (th!5*is*.a phvsicj"an"" I-qJbySjSiA[*S"Sfl,:ult).*ThiS"l*"qm w-ill arS-iSl-ilUdst-ff]:Ilulug appropjilrte candidates and PCIA dosases. The following applies: l. A single S{isubggtan-e""p"lls-infusion site can usually accept 2'3 ml/hour, 2. Highly concentrated solutions (e.g., hydromorphone I or 10 mg/ml,-er morphine *&' 505 mg/ml)-.or.fu,ilanyl l50mpglmil are used for $#r$h9ulAngp]S infusion, and rates are in tenths of a millimeter (0.1 mlftour).

:[Aol7ls

i.A

9'!

$,t ::,,i

nrturufacturer's

7,

\},9

suhcutaner:us injectioirs, bilateral subclavicular chest wall. or posterior kr be pinchq{betu,'een scapular area: the site slioulcl allou,a lat fi]ll of',irt leAst thurnb and inclex finser. Avoid areas that are scarrecl. infected, initated, erlematous. ht$v. highlJ vasc,pla{. or rlear the waistline. Caphexia-is net a contraindic"atiotr for sqbcsJ.4g-e,.gLs access,- ajdrsuChgailsbjr..ulss--Lu-iry*b"s*limtlqd, -[la-$-tite is prepped IV catheter and shoulcl be covered with a transparent dressing. ASpUAtipn ;h.g"nld -N-Q'I-"r"g"s-gtt" in-bft:-oAr"e-t#:, -l,bS-srLE "Sl:-Q-ttkl he mouitoled accordin$ to the su-ne. paranreters as an IV site lbr erlthema,-lllduration, lCAklne, -b-l-e""Edrn&"-qds$*r.in:fection. Ol.1i$SueSl$:neh,Jll,p-$Site should be changed by

irls-Lt'Uctioni."in

needleisplacedat-o{!degqgqalgJg.==A9-eg.4i4$J_s
anato",pical sites

NE dfia jrl&s whcr6.ilttl.itl ebrib 6orn a

usetl

fbr

l"

the nurse minimum every 7 days, or more often

leaking).

if

necessary (erythema, edema,

&{, fhe administratiu

pre"yptl!-u0i.s!3 kmg

4,5-.Dosing is the same as for IV infusion; however, a longdr initial drug onset time (apprqXinlqtely 20 rninples) must be allowed for 4ts*e-slower absorption via the Se subcrttaneous route, {t0.-*----Change PCA bag/syringe every 24 hours for UCH mixed solutions and every 72 hours for pre-mixed solutions, Change the tubing every 96 hours. {;,f|*"^"""Jhe key to the PCA pump will be kept within a secured designated area, e.g., Pyxis machine on each unit,

-[gl.a&:$jffi

vro-

in e.

1L$. ,."^".^If a patient experiences an adverse event related to sedation or respiratory

depression, examine the medication concentration and pump settings to assure they are

c15841 I

Page 5

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Patient Controlled Analgesia (PCA): Adult and Pediatric

correct. If no human olrors are discovered: 1) Return the PCA pump -w-ilh lAg to Biomed for inspection. The pump must not be retumed to use or to Central Supply; 2) The IV bag and tubing must be returned to the Pharmacy. Contact the Pharmacy Manager on call (303-266-0661) for instructions on disposition ofthe IV bag and tubing, based on time of day and day ofthe week.

3. Initiation of PCA Therapy

A.
Infusion medication and labeling

t.

lvlantr*"aettner prehnixed LJCH phar.nggy-baiphed-morphlne synngeq (30 ml' +I mg/ml)-antl*tJ,l{=pharnm,oy-preparotl--hydromorphone bilgti"pyringe-s "(510 ml, &3-l mg/ml), and fentanyl baes-$,rgtCgl(+$030 ml, *i0 mcg/ml) are stocked in the Pyxis machine.

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tl L&d4o$loufl'ede'@t
sr+,iiieog

&

tqncdii$i{$i-s:i,'

SIiglsr

Ihetapts$

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tf,t0arttll"s&*p6(rAidrisrsqry'

Goilfi&0t [At?S]l

ctisrged tq rflict ncri,

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3' Gather equipment: wjth

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,

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arlr*

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fu^

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4.

c.

PCA tubing with Y connector

a--+gA*xte*$ot++ubiftg
*d. Syringe;.bag with ordered medication ,It..tle"..U,T11,=,,flilll!.siv"e.=.!la$l9,,tselssL=l-Y.,,B$=gl$-ee""i.s"!"..ls,..hEtrg,..u!sd..,LY.itlt...a c"o$tiquoqs rate inl'using vip tlts Alari$ I.YL the l'crllou,i,pg adllitional gquiirment is
rcquirecl:
a- " Commcnt IAOIEI: hsefid ro clariry nftded
ilqns fgr large vohme PCA dqsing

Alirris tCt.i-.with pne LYP modulp

tIADI)
locklrox

.(see

Adrninister Ccxrtrclllecl Sirbstance infirsions in Non-lCU Care Areas)

"Kalzer Bulleli"$" Holv to'

b-- Al al"is qorrtr oll ed. slr,bstarlge_t}lJline

c.

Page 6

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Patient Controlled Analgesia (PCA): Adult and Pediatric

&. _ -CADD lq$"kb.p.x k"qy4,5.Wash hands. 5, {t.Y erify IV or $uhcutan eou $,,$i-te patency. 7. Follow the manufacturer's instructions for setting up, loading, priming the tubing, and programming the PCA
4t,8

lY

mecliqaXions adr:qifi,.s"t-ered to

rnaxirnurn and minimurn ranges tr:r IICA basal rai:es. ilemand dclses. boluses. loaeling djrses. arid.,,lockout ti"{]re.s. There arg.three diflbrent eate"gsrries of patient pnder these

"lAliqnts. TheSS C}arcirirjls inch'rde ha,rd a0d soft

Suairk

Uust &!)-Label tubing with date and time and sticker. .8,10. Two RNs must independently verify drug, volume, concentration' and rate including all pump settings against the orders.
lnaintenan
PCIA tubins. Cconnect the PCA

p-rsg-ammng-g]c-a"ump" lhs,ssllesl ca!.egprv*a[-pat]-c$l -(sffirdsJ-"$ he selecteci in order fbr the apllropriale Cuatclraili to apply.
JrsIL

tnt

l$-qpis,i*tl--n"atve-opii:ui*1p"1-qiurl, "and Pdlliiiu"Y-"e"ea"r"eiQn"c-olegv.

(Jilpgx*t&r

7 ts-)4nts

' ! \uau&
)

L^n

Y,"l
hFerted-P$iA!ait{.f4ul'

exifiiex6

tubing to the l$,12.*Instruct the patient and family/sigrificant other on the use of PCA.

4, Recommended
A.
are:

Monitoring

Recommended patient monitoring includes assessment and documentation of vital sigrs, sedation level, and pain intensity per PCA orders. Recommended monitoring parameters

2, Respiratory rate and sedation level every I hour x 12 hours, then every 2 hours x 12 3. Ifthe
hours, then every 4 hours until the PCA is discontinued' PCA dose is increased (basal rate started or increased, demand dose increased, lockout frequency decreased, RN bolus given), temporarily increase the respiratory rate and sedation level monitoring to every 30 minutes x 2' Assessment of the sleeping patient: a. Respiratory status should be observed without awakening the patient. Arousal will stimulate respiration and potentially mask pending problems. b. Observation should include the depth and regularity of respirations and

1,

Heart rate, blood pressure, temperature and pulse oximetry every 4 hours

4.

c.
d. e.

listening for snoring. Shallow respirations, periods of apnea, or snoring may be a sign of over sedation or respiratory trouble and the patient should be awakened to further assess. If there is any question about whether the patient is sleeping normally or is sedated, they should be awakened to further assess. If respiratory rate and status are assessed as normal as noted above, it is not required to awaken the patient to assess sedation.
<':i::

,eofiitfiGnt fAf,9$rqilaobd ta {6.fle{t tary

spdation acale

in um; reference inretted belorv

Centered

Formatted:

Formatted Tabl
Page 7

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Patient Controlled Analgesia @CA): Adult and Pediatric

4-tiren'sy
Z:Au-ldyuts

$-s+eeni*e-are$sal+e

I +-:ne*-.a++le+e-ale*se

l?:di$Seu{++e-aress*

I-*"-None to minimal sedatir:n Awake. aware. alert: snontaneous sustained interaction

Restful. drow-sv, dozine. liphtlv sleeninu: sott voice. no tactile stimulus reouired or lisht touch. sustains interaction

3--Moderate Sedation
Sleeninp. soft to normal voice- lisht touch. limited interactiolr

*::Msd-ffale-[Edalipn
Sleenins. normal to loud voice. lisht touch- follows simo[e commalds
5_- Qeqp $edation

Sleepinq, airway anci ventilatiolr rnay be irnpairecl. lcxrd voice. intense tcl nr'rxiorrs tactile stimu'lirs- nurnoseful resnonse or non-nurnoseful movement

fficnsralAns$thslle
S

lgepirls. oirway And venti latiorr, likel), -impaired. loud voice. noxiou

B,
C. D.

Increasing somnolence can be a key indicator

of pending opioid induced respiratory

depression. Assess the patient's pain intensity at least every 4 hours and within doses or rate/medication changes. Assess the patient for the following side effects and treat as needed: 1. Nausea and/or vomiting

t hour after bolus

E. F.

2. Pruritus 3. Urinary retention 4. Constipation

Immediately noti$ the ordering sgrvicg for respiratory rate less than
sedalion level of Ifre$iift{tqly.::r,elei:nass

l0

per minute,
. ..-

#n*e rr:sedalim,.Ietel of {S &ot a}ild tp,mou*}, ]stop_ infusion and administer naloxone 0.1 mg IV STAT, may repeat every 3-5 minutes x 3
rk&'8
doses to a total of 0.4 mg.

.$an

to ar{ruse),,or iaadequate pain reliof,

G. The above monitoring

parameters are minimum standards and should be increased as wananted by patient condition and orders.

5. Documentation
A.
The nurse is responsible to document the following on the appropriate patient information record: Heart rate, blood pressure, temperature and pulse oximetry every 4 hours, 2. Respiratory rate and sedation level every I hour x 12 hours-, then every 2 hours x 12 hours, then every 4 hours, 3. Two RNs must independently verify drug, volume, concentration, and rate including all pump settings against the orders when: a. Initiating the PCA infusion b. Accepting patient from another floor Changing shift (with off-going RN to oncoming RN)

c.

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Patient Controlled Analgesia @CA): Adult and Pediatric

rl.*Changing any settings or changing drug
,*,p-,Chan{dtrg an empt

4. Two RN's must witness and document wasting of controlled substances* 5. The number of PCA button demands/deliveries and the total amount of medication 6. 7.
A.
(mg or mcg) used every 4 hours. After recording these amounts, clear the 4 hour shift total to reset the pump for the next 4 hour total. Pain intensity at least every4 hours and within I hour after bolus doses or ratelmedication changes, $gide effects/complications. Patient and family education on the Interdisciplinary Teaching Sheet.

6, Education
Where appropriate, provide patient education sheet "Patient Controlled Analgesia (PCA)" (DOD# PED00105-0902 available in spanish). Review with patient and family the principles of PCA therapy and proper use. Identify that no one but the patient is to administer a PCA dose.

REFERENCES;
Parkei. M. & Herrderson, K. (2010). Altematiyq lnlusipajcacs,r-Dey-ipes.-ln-]\d,*AlExan-cl-e:, . A. Cjorrigan, L. Corski, J. Hankins BQ-ed AilprQsih (pp, 5i6":i?il. $I,"I*otitr MO; S.a"uRsiers Elseyisl fl,0"8" l?") 1",2. -American Pain Society (2008). Principles of Analgesic Use in the Treatment Of Acute Pain And Cancer Pain (6th Ed.). American Pain Society, Skokie, IL. (LOE VI) ,} 3. _Lehmann, K. (2005). Recent developments in Patient-Controlled Analgesia. Journal of Pain and Symptom Management. 29(55) S72-S89, (LOE D 3",4. ,Institute for Safe Medication Practice Newsletter (2009). Beware of basal opioid infusions with PCA therapy. March 12 issue, (LOE V) 4,5.. ...Macintyre P. (2005). Intravenous patient-controlled analgesia: One size does not fit all. Anesthesiology Clinics of North America. 23,109-123. (LOE VI) 6. McCaffery, M. & Pasero, C., (2010). Pain Assessment and Pharmacologic Management. St. Louis: Mosby. (LOE VI) Pharrnacqlegic Sedation Scale. Clinical Nurse Specialist.26{3);140-148. {LOE ?) &9. Pasero, C. & McCaffery M., (2005). Authorized and unauthorized use of PCA pumps. American Journal of Nursing, 105(7), 30-32. (LOE VI) ?",1/......... Pasero, C. (2009). Assessment of sedation during opioid administration for pain management. Joumal of Perianesthesia Nursing. 24(3):186-190. (LOE VI) &10.. Patient controlled analgesia by proxy. Sentinel Event Alert. Dec 20, 2004. Available at

t.

-'

irrfEsims}NBEDS.LOEl.'
Formatted: Font: Italic

Ite{t{*nce foi suGutarreoiis

Rduq,9,,fot

http://wwwjointcommission.org/SentinelEvents/SentinelEventAlert/sea_33.htm, Accessed 9t812005. (LOE V)

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