Identifying and Addressing Medical Errors in Pain Mismanagement

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This discussion of how to identify system-level errors in pain management should be useful to both health care systems and practicing clinicians. PATIENT SAFETY

Identifying and Addressing Medical Errors in Pain Mismanagement PATRICIA L. STARCK, DSN, RN GWEN D. SHERWOOD, PHD, RN JEANETTE ADAMS-MCNEILL, DRPH, NP-C, AOCN ERIC J. THOMAS, MD

or at least three decades, health professionals have documented that undertreatment of pain is pervasive, occurring with one-half to onethird of hospitalized patients. Various measures have been tried to correct this problem, including development of national guidelines by governmental agencies,1 professional group associations,2 and international organizations.3 Yet the problem persists. Recently, the Joint Commission on Accreditation of Healthcare Organizations (Oakbrook Terrace, Ill)4 has specified comprehensive pain management standards. One requirement is that the organization include a statement regarding its commitment to pain control in its mission statement, policy manual, and/or bill of rights. The Joint Commission specifies patient rights and responsibilities and gives specific directives for caregivers; it also requires incorporation of pain

F

assessment as the fifth vital sign and use of a consistent rating scale. Why has this area of clinical excellence been so difficult to achieve? Will standards and requirements at long last ameliorate this problem? In this article, we propose an adjunctive model to be used as organizations try to bring about change in the clinical culture and in the behavior of caregivers and patients/families. In recent years, the health professions have taken significant steps in declaring their intent to openly examine and confront medical errors occurring in the process of delivering care. The health care professions have examined theories about why errors occur5–8 and the experiences of other industries.9 The conclusion has been that many errors in health care are likely the result of system failures rather than of isolated actions of practitioners. Investigators have used this approach to document the system errors that

Patricia L. Starck, DSN, RN, is John P. McGovern Distinguished Professor and Dean; Gwen D. Sherwood, PhD, RN, is Professor; and Jeanette Adams-McNeill, DrPH, NP-C, AOCN, is Associate Professor, University of Texas–Houston Health Science Center School of Nursing, Houston. Eric J.

Thomas, MD, is Assistant Professor, University of Texas–

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Houston Health Science Center Medical School, Houston. Please address requests for reprints to Patricia L. Starck, DSN, RN, University of Texas–Houston Health Science Center School of Nursing, 1100 Holcombe Blvd, Suite 5.500, Houston, TX 77030; phone 713/500-2002; fax 713/500-2007; e-mail [email protected].

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THE JOINT COMMISSION Article-at-a-Glance Background: There is strong evidence in the pain management literature that undertreatment of pain is pervasive despite several approaches, including use of national guidelines, to completely correct the problem. Although the concept of medical errors has primarily been concerned with adverse events, it is not unreasonable that mismanagement of pain could also be classified as a medical error. Errors of pain management: Error types can be classified as errors in assessment and documentation, errors in treatment and management, and errors in patient education. Within each of these categories, errors may be skill-, rule-, and/or knowledge-based, as suggested by evi-

lead to various adverse events6,10 and to design interventions to prevent these errors.11–13 The Institute of Medicine’s report To Err Is Human: Building a Safer Health System14 has captured the attention of the public and professionals alike. It defines error as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”(p 3) The report documents the incidence of errors in health care delivery and the high price of adverse events in human and economic terms. In essence it calls for a systems approach to preventing errors and advocates four broad approaches, including bringing national attention to the problem, identifying and learning from errors, raising standards and expectations, and creating safety systems in health care organizations. The original work on error in human systems and the development of a model by James Reason8 formed the basis for the pain management framework presented in this article. Reason made distinctions between slips and lapses (skill-based problems) and mistakes (rule-based and knowledge-based errors). Skill-based performance problems are classified as either inattention or overattention (for example, making an attentional check at an inappropriate point). Rule-based performance errors are caused by either misapplication of good rules or application of bad rules. Finally, knowledge-based errors arise from incomplete or incorrect knowledge. Among the types of knowledge-based errors are overconfidence (in evaluating the correctness of one’s knowledge), confirmation bias (a plan put in motion resists change, even in

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dence of mismanagement in various aspects of the pain management process as found in the literature. An examination of the root causes of medical errors may be used to detect system failures. At least ten steps can be identified in the process of pain management in the acute care setting, starting with admission, and errors can potentially occur at any step. A redesigned system could help improve error rates by incorporating use of skills, rules, and knowledge for effective management. Conclusion: A new approach to the unsolved problem of pain management in acute care settings is proposed; this approach uses the concept of mismanagement as a medical error.

the face of new information; looking for confirming versus disconfirming evidence), illusory correlation (performing poorly at detecting covariation), halo effects (showing a predilection for single orderings and an aversion to discrepant orderings), and problems with causality (tendency to oversimplify causality). Causality problems include thematic vagabonding (treating an issue superficially when having difficulty dealing with a topic; leaving it alone so as not to face one’s helplessness) and encysting (disregarding some issues and focusing on others for success in a desire to escape one’s inadequacies). In Table 1 (p 193) pain management errors in the acute care setting are presented according to Reason’s types of errors. Helmreich and other researchers15–17 have used a systems approach to error in the airline industry. In recent years, these researchers18,19 have reported using this same approach in studying teamwork and system errors in the operating room. One lesson learned from the aviation safety experience is that communication and teamwork are important factors. Hierarchies in status affect communication; if junior people are not free to question senior people, communication that might prevent errors can be hampered. If senior members do not encourage feedback from junior team members, valuable safety checks may be lost.16 Similar communication problems among providers and patients may impede adequate pain control. The following anecdote from clinical practice illustrates this point. A patient was admitted to the emergency room with an open fracture of an extremity. The patient was

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in obvious pain. The physician examined the patient and wrote orders, including a stat x-ray. Noting that the physician had not left an order for pain medication, the nurse followed the physician out of the examining room and asked, “What can he have for pain?” The physician replied, “Get the x-ray first,” indicating that his orders as written were not to be questioned. The concept of medical errors has primarily been concerned with adverse events, and rightly so; however, it is not unreasonable to argue that mismanagement of pain should also be classified as a medical error. Doing so may reveal system problems, such as the communication and teamwork issues noted in the anecdote, that may be corrected at the systems level. While death or serious injury may not occur, inadequate pain control results in unnecessary pain and suffering. Furthermore, mismanagement of pain has negative physiologic, psychologic, and financial consequences. Ferrell20 cited slowed healing, higher complication rates, anxiety, sleep disturbance, and lowered quality of life as results of poorly managed pain. Unscheduled readmissions for pain control, delayed return to work, and longer periods of poor role function/performance compound the problem, resulting in a substantial economic impact.21 The compilation of research regarding pain management suggests that, for the most part, the science is known and evidence regarding best practice is clear. However, behavior in adhering to existing guidelines is problematic. Therefore, developing a new model for this problem would begin with the goal of optimal pain relief for all patients. Systems would then be designed that make it impossible or extremely difficult not to attend to the patient’s pain. An analogy from the automobile industry might illustrate this point. In the past, cars would lurch forward when gears were shifted improperly. Now newer cars require that the driver have a foot on the brake before gears can be shifted from the park to the drive mode, thus preventing an adverse event. Undertreatment is believed to be associated with physician fear of being accused of abusive use of narcotics, but also it is believed that undertreatment is related to other factors. A medical board recently disciplined a physician for the undertreatment of pain,22 which illustrates the prevailing practice of finding fault, blaming, and punishing individuals. A newer approach based on the lessons learned from the avia-

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Table 1. Reason’s Categories of Human Error as Applied to Examples of Errors in Pain Management*

Skill-Based Errors ■ A patient who isn’t complaining of pain is not in pain. (inattention) ■ It is difficult to explain pain management to patients with language problems. (inattention) ■ Care providers fail to check pain level after medication is given. (inattention) Rule-Based Errors ■ When prn medication orders are for every 3–4

hours, medication should not be given before 3 hours and preferably 4. (application of bad rule) ■ Intramuscular injections give faster medication delivery than do oral medications. (misapplication of good rule) ■ Patients with a history of drug abuse should be treated sparingly with narcotics. (application of bad rule) Knowledge-Based Errors ■ Pain is to be expected in the elderly. (inadequate

knowledge) ■ Pain is normal after surgery. (inadequate knowledge) ■ Patient satisfaction is a good measure of effective

pain management. (incorrect knowledge) * prn, as needed.

tion safety model would be to address this problem at a systems level.

The Errors of Pain Management Reason8 defined error as “the failure of intended actions to achieve their desired consequences.”(p 7) What then are the errors in pain management? A classification of pain management errors is presented in Table 2 (p 194). Within each of three main categories, errors may be skill-, rule-, and/or knowledge-based. This classification is based on widespread evidence of mismanagement in various aspects of the pain management process as found in the literature. Findings continue to reveal that far too many patients are undertreated for pain.23–25 Starck et al,26 in a study of hospitalized patients, found that 11% of patients reported asking for pain medication and never receiving any. McNeill et al,25 in a study of hospitalized patients in a rural area, found that one-third of patients were inadequately

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THE JOINT COMMISSION Table 2. Classification of Pain Management Errors

I.

Errors in Assessment and Documentation A. Discrepancy by age B. Discrepancy by sex C. Discrepancy by ethnicity D. Documentation failures

II. Errors in Treatment and Management A. Scheduling B. Analgesic choice C. Route choice D. Inadequate use of adjuncts III. Errors in Patient Education A. Patient/family education B. Patient satisfaction C. Beliefs/myths

treated for pain. The researchers used a variation of the Pain Management Index (PMI; Cleeland et al23) comparing “worst pain” score with strongest analgesic administered. The researchers also found that only 66% of patients had actually received an analgesic within the previous 24 hours, even though 98% of patients had indicated having pain in the past 24 hours and all the patients had had analgesics prescribed. Examples from the literature are now presented for each of the types of errors represented in the Classification of Pain Management Errors—starting with errors in assessment and documentation. Errors in Assessment and Documentation Discrepancy by age. The elderly and other vulnerable groups are at greater risk than others for poor pain management.27,24 McNeill et al25 found statistically significant differences in pain management between elderly and nonelderly hospitalized patients. They reported a significant negative correlation (r = –.30; p = .002) between age and the PMI treatment score (defined as the patient’s worst pain score compared with the most potent analgesic), indicating less effective pain management for elderly patients. Further analysis demonstrated that 35% of older patients with medical conditions and 26% of older patients who had surgery were inadequately treated for pain. Wynne et al28 called for new strategies to assess pain in the elderly, especially the cognitively impaired elderly, for whom a combination of instruments was recommended.

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Unruh29 analyzed the literature for variations in clinical pain experiences by sex and drew the following conclusions: Women are more likely than men to experience a variety of recurrent pains; women report more severe levels of, more frequent, and longer duration of pain than men; women are at greater risk for pain-related disability, but respond more aggressively through health-related activities than men; and women are more vulnerable than men to unwarranted psychogenic attributions for pain by their health care providers. Gear et al,30 in a study of patients who had surgery for removal of third-molar teeth, found that both nalbuphine and butorphanol produced significantly greater analgesia in women than in men. Currently, researchers are investigating sex differences in both pain threshold and coping ability for pain.31 Discrepancy by ethnicity. Members of ethnic minority groups may be as much as two or three times as likely as others to be undertreated for pain.23,31 Cleeland et al23 found that 74% of such patients were inadequately managed for cancer pain and that such patients were three times more likely to have inadequate pain management than were other patients. Ng et al31 found significant differences in analgesic administration by ethnic groups in patients treated surgically for limb fracture. Whites received 22 mg per day of morphine equivalents versus 16 mg for blacks and 13 mg for for hispanics. Todd et al32 also found ethnicity to be a risk factor in pain management in emergency care. Documentation failures. In a chart review of various clinical hospital units, Clarke et al33 indicated that 76% of the charts showed no evidence of nurses’ use of a patient self-assessment tool for pain. However, descriptions other than patient selfassessment were found in 79% of nurses’ notes and 51% of physicians’ notes. The review also revealed gaps in documentation, such as the administration of pain medication without written documentation of pain. Notes were also found such as “pain better,” with no previous documentation of pain assessment or intervention. Discrepancy by sex.

Errors in Treatment and Management Errors in the treatment and management of pain are also frequently reported; most of the errors seem to be knowledge based.

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Agency for Health Care Policy and Research (AHCPR) guidelines1 clearly advocate administering analgesics on a regular schedule when pain is to be expected, for example, the first 36 to 48 hours after surgery. When medication is given on a prn, or “as-needed,” basis, unnecessary delays may occur and patients may experience peaks and troughs of pain and pain relief. Scheduling medications helps to promote a constant blood level of analgesia. Jairath and Kowal34 found that 68% of patients anticipating major surgery identified scheduled medication as the most effective treatment approach. These authors recommended mandated time-contingent dosing for the early postsurgical period. Analgesic choice. The use of meperidine is problematic for several reasons.1 First, the medication produces clinical analgesia for only 2.5 to 3.5 hours but is usually ordered every 4 hours or as needed. Second, the commonly ordered dose of 75 mg is equal to only 5 mg to 7.5 mg of morphine. For the patient to receive the analgesic effect of 10 mg of morphine, the meperidine dosage would need to be 100 mg to 150 mg every 3 hours. Third, meperidine can be toxic for patients with impaired renal function and may create druginteraction problems. Yet it continues to be used in the clinical area for postoperative pain. The World Health Organization3 classified analgesics into three levels, from weakest to most potent— that is, nonsteroidal, anti-inflammatory agent (such as Tylenol); weak opioid (such as codeine); and strong opioid (such as morphine). A choice of using Tylenol to alleviate severe cancer-related pain is an example of an error in analgesic choice. Route choice. McNeill et al24,25 reported that medications are often administered intramuscularly despite the AHCPR’s1 recommendation to use the oral or intravenous route. As postsurgical patients constituted a large proportion of the patients in both studies (68%24 and 80%25), it could be assumed that intravenous access was frequently in place, which would have lessened the need for intramuscular injections and the associated discomfort. Technologic advances, such as patient-controlled analgesia (PCA) pumps or epidural catheters, for example, were rarely used. Inadequate use of adjuncts. Nonpharmacologic approaches are often not a part of the plan of pain management, although their effectiveness and patient Scheduling.

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preferences have been documented. Ferrell, Torry, and Glick35 found that massage therapy significantly reduced levels of pain and anxiety, and it enhanced feelings of relaxation, by an average of 58% in hospitalized cancer patients. Furthermore, all physiologic measures (heart rate, respiration, and blood pressure) tended to decrease from baseline for patients receiving massage therapy. In a chart review of various hospital clinical units, Clarke et al33 found that documentation for use of nonpharmacologic treatments was minimal to nonexistent. Consistent with the findings from McNeill et al,24 in a follow-up study involving a predominately Hispanic population,25 patients ranked prayer as the most frequent nondrug form of pain control. Furthermore, there was little use of noninvasive therapies, such as relaxation and distraction, although a somewhat higher proportion of Hispanic patients reported using these approaches25 than did white patients.24 Neglecting the powerful value of adjuncts such as relaxation and distraction is a disservice to patients of all ethnic groups. Errors in Patient Education Many errors in pain management can be traced to information deficits (knowledge based) and miscommunication with the patient and family (skills and/or rule based). The most troublesome are discussed here. Patient/family education. Yeager et al36 demonstrated that patients with cancer-related pain seen in outpatient settings and their family caregivers lacked knowledge regarding addiction, tolerance, and side effects of medication. Patients and their family caregivers should receive proper information about patient goals and rights to effective pain management, as well as the importance of pain management and its role in the recovery/treatment process. This instruction is especially important with patients/families who wish to please and not complain. They should also receive information of side effects of pain medication and how these side effects can be addressed. Instruction should include debunking commonly held myths about the danger of too much pain medication. Such information given on admission should also be repeated and reinforced periodically as needed. In an urban setting only 67% of patients recalled a caregiver’s informing them that pain management was a

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THE JOINT COMMISSION priority in their care; other studies report similar rates regarding provision of this information.37,38 AHCPR has developed both clinician and lay versions of the pain management guidelines that can be used in educating patients and families.1 Von Roenn et al39 found that 86% of physicians who treat cancer patients believed that poor pain assessment was the single most important barrier to adequate pain management. To improve assessment, patient/family education must emphasize the importance of reporting pain soon after its onset. Patient satisfaction. Evaluation of patient satisfaction with care received is an important measure of the quality of care. However, in the area of pain management, there are confusing issues. Patients may indicate satisfaction with nurses’ and physicians’ pain management yet still be in pain or report high intensity of pain.24,25,40 Patient satisfaction in spite of poor pain management has been a baffling phenomenon to researchers and clinicians alike. Furthermore, it is not clear what factors influence patients when in pain to decline more medication for pain relief. Ward and Gordon38 and Miaskowski et al37 proposed that perhaps patients are satisfied when they feel that their care providers attempt to manage their pain. Moreover, Ward and Gordon40 suggested that patients may anticipate the peaks and troughs of the pain experience and thus are not dissatisfied when pain occurs. The cycle of increased pain, administration of a prn analgesic, and pain relief is perhaps an expected occurrence, particularly for postoperative patients. McNeill et al24,25 reported similar findings yet found a significant inverse correlation between patient satisfaction and current pain intensity (r = –.25; p = .02 in an urban patient population and r = .49, p = .001 in a rural patient population). This inverse correlation was also found between patient satisfaction and general level of pain in the past 24 hours (r = –.28; p = .01; r = –.30; p = .003, respectively). Beliefs/myths. McNeill et al24 found that on written questionnaires patients had little agreement with myths and false beliefs regarding pain management, such as “taking medication for pain leads to addiction.” Mean scores on seven statements ranged from 1.10 to 2.74 (0–5 scale; 0 = not agreeing with false belief). Similar results were found with a primarily Hispanic population.25 For both studies, neither patient satisfaction nor agreement with the myths and false beliefs correlated

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significantly with patients’ desire for additional medication when in pain. Patients’ responses to an open-ended question regarding their reason for declining more medication indicated that several of these misconceptions about pain or its management influenced their decisions. They make statements such as “I don’t want to be all doped up” and “I don’t want to get addicted.”40 Even though patients identified the fear of becoming addicted as an untrue statement on a research questionnaire, they acted as if it were true in their individual situations.

Root Causes of Pain Management Errors An examination of the root causes of medical errors that is based on the Classification of Pain Management Errors can be used to detect system failures. The actors and their roles are depicted in Figure 1 (p 197); they are primarily nurses, physicians, and patients, although others may also be involved and might contribute to the problem at each level. At least ten steps can be identified in the process of pain management in the acute care setting, starting with admission (Figure 2, p 198), and errors can potentially occur at any step. These ten steps represent a systematized approach in common use at several hospitals where research was conducted during the past five years.24–26,41 A redesigned system could help improve error rates by incorporating use of skills, rules, and knowledge for effective management. Requiring pain levels to be assessed and charted as the fifth vital sign is a systems approach that is rule based. Other components of the system would need to be redesigned to eliminate most, if not all, errors in pain management. A new model for pain management would need to address each category of the mismanagement of pain and involve attention to the various steps in the process.

Summary and Conclusions A proposed new approach to the unsolved problem of pain management in acute care settings uses the concept of mismanagement as system error. The approach would follow that used in the aviation industry and, more recently, the health care industry for adverse events. Reason’s model of errors as being skill-, rule-, and/or knowledge based can be found in pain management examples. The three classifications of error in pain management are proposed as errors of assessment and documentation, errors of treatment and manage-

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Analysis of Poor Pain Management in Acute Care Settings Type of Error

Primary Responsible Party

Assessment and Documentation

Nurse

Not specifically and systematically assessed Not recorded/documented Discrepancies by age, sex, and ethnicity Incorrect choice of analgesic, route, dose, schedule Inadequate use of adjuncts

Physician Treatment and Management

Patient Education

Description of Error

Nurse

Gives less dosage or less frequently if a range is ordered

Patient

Not requested or declined when requested

Fear of addiction

Unaware of goal/rights Fear side effects “Need to save for when really needed”

Fear of losing awareness Desire to please

Figure 1. The analysis of pain management errors in acute care settings is examined by type of error, the primary person who is responsible, and

a description of the error.

ment, and errors in patient education. At least ten steps in the process of managing pain in acute care settings are points at which errors can occur. To design systems to prevent mismanagement for pain, there is a need to conduct research to

elucidate types of errors, team communication issues, barriers, and system-level interventions. A proposed research agenda might address the questions listed in Table 3 (p 199). The ultimate goal is to give patients what they have a right to—optimum pain relief. J

References 1. Agency for Health Care Policy and Research, Public Health Service, Acute Pain Management Guideline Panel: Acute Pain Management in Adults: Operative or Medical Procedures and Trauma: Clinical Practice Guideline. AHCPR Pub. No. 920032. Rockville, MD: U.S. Department of Health and Human Services, Feb 1992. 2. American Pain Society Quality of Care Committee: Quality improvement for the treatment of acute pain and cancer pain. JAMA 274:1874–1880, 1995. 3. World Health Organization: Cancer Pain Relief 2nd ed. Geneva, 1990.

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4. Joint Commission: . 5. Leape LL: Error in medicine. JAMA 272:1851–1857, 1994. 6. Leape LL, et al: Systems analysis of adverse drug events. JAMA 274:35–43, 1995. 7. Buerhaus P: Lucien Leape on the causes and preventions of errors and adverse events in health care. Image 31(3):281–286, 1999. 8. Reason J: Human Error. Manchester, UK: Cambridge University Press, 1990. 9. Perrow C: Normal Accidents: Living with High-Risk Technologies. New York: Basic Books, 1984. 10. Petersen LA, et al: Does hous-

estaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 121:866–872, 1994. 11. Bates DW, et al: Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 280:1311–1316, 1998. 12. Evans RS, et al: A computerassisted management program for antibiotics and other antiinfective agents. N Engl J Med 338:232–238, 1998. 13. Petersen LA, et al: Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 24:77–87, 1998.

14. Kohn LT, Corrigan JM, Donaldson MS (eds): To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine, National Academy Press, 1999. 15. Helmreich RL: Anatomy of a system accident: The crash of Avianca Flight 052. International Journal of Aviation Psychology 94:265–284, 1994. 16. Helmreich RL, Merritt AC: Culture at Work: National, Organizational, and Professional Influences. Aldershot, UK: Ashgate, 1998.

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THE JOINT COMMISSION Steps in the Process of Acute Care Pain Management from Admission Patient in pain or at risk for pain

Steps 1

Physician’s prescription (order)

prn

Scheduled

Nurse assesses

Patient complains, requests

Chart

Chart

Nurse checks orders

Yes

Acquire

Nurse requests renewal/ revision of orders if pain persists

No

In stock

Nurse assesses, administers, evaluates, and charts

Contact & request order

2

3/4

5

6

Prepare

7

Check/administer

8

Chart results

9

Reassess

10

Figure 2. The ten steps in the process of acute care pain management begin with recognizing people as being at risk. The type of orders physicians give starts the process of management in motion. This flowchart identifies various paths of action thereafter. The “scheduled” pathway leads to quicker and more positive responses. prn, as needed.

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Table 3. Questions for a New Research Agenda

1. What are the root causes of unresolved problems in patients who have pain, in each type of setting—that is, acute care, rehabilitation, home health, and so on? 2. Does the Classification of Pain Management Errors serve to capture all types of errors in pain management? 3. What are the patterns of communication between physician and nurse team members regarding unresolved pain? Do nurses perceive that they should not question the physician orders when those orders do not comply with national guidelines or with the nurse’s own knowledge base? 4. Do physicians encourage feedback about the patient’s pain in rounds or at other opportunities? This analysis of team communication could offer new insights into this unexplored dimension of pain management. 5. What do physicians/nurses/patients perceive to be barriers to achieving effective pain management? Can these barriers be classified as errors that were knowledge, skill, or rule based?

6. What are the classifications of pain management errors according to Reason’s* model of skill-based, rulebased, and knowledge-based errors? For example, failing to give the oral dose equivalent to the injectable dose is a knowledge-based error; routinely using prn instead of scheduled dosing is a rule-based error; and ineffective communication with the patient to overcome fear of addiction is a skill-based error. 7. What system-level change would prevent errors in assessment and documentation, treatment and management, and patient education? Will the institution of pain as the fifth vital sign improve assessment? 8. What system-level changes could relieve physician anxiety about perceptions of sanctions for abusive use of prescription narcotics? 9. What improvements would be documented with systemwide improvement in pain management? * Reason J: Human Error. Manchester, UK: Cambridge University Press, 1990.

References (continued) 17. Helmreich RL: On error management: Lessons from aviation. BMJ 320:781–785, 2000. 18. Helmreich RL, Schaefer HG: Team performance in the operating room. In Bogner MS (ed): Human Error in Medicine. Hillside, NJ: Lawrence Erlbaum and Associates, 1994, pp 225–252. 19. Schaefer HG, Helmreich RL: The importance of human factors in the operating room. Anesthesiol 80:479–482, 1994. 20. Ferrell B: The impact of pain on quality of life: A decade of research. Nurs Clin North Am 30: 609–624, 1995. 21. Grant M, et al: Unscheduled readmissions for uncontrolled symptoms: A health care challenge for nurses. Nurs Clin North Am 30: 673–682, 1995. 22. Oregon Medical Board of Examiners: Doctor sanctioned for undertreating patients’ pain. (Jan 11, 2000). 23. Cleeland C, et al: Pain and its treatment in outpatients with

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metastatic cancer. N Engl J Med 30:592–596, 1994. 24. McNeill JA, et al: Assessing clinical outcomes: Patient satisfaction with pain management. J Pain Symptom Manage 16:29–40, 1998. 25. McNeill JA, Sherwood GD, Starck PL: Pain management outcomes for Hispanic hospitalized patients. Pain Management Nursing 2(1):25–36, 2001. 26. Starck PL, et al: Development of a pain management report card for an acute care setting. Adv Pract Nurs Q 3(2):57–63, 1997. 27. Ferrell BA: Pain management in elderly people. J Am Geriatr Soc 39:64–73, 1991. 28. Wynne CF, Ling SM, Remsburg R: Comparison of pain assessment instruments in cognitively intact and cognitively impaired nursing home residents. Geriatric Nursing 21(1):20–23, 2000. 29. Unruh AM: Gender variations in clinical pain experience. Pain 65:123–167, 1996. 30. Gear RW, et al: Kappaopioids produce significantly greater

analgesia in women than in men. Nat Med 2:1248–1250, 1996. 31. Ng B, et al: Ethnic differences in analgesic consumption for postoperative pain. Psychosom Med 58:125–129, 1996. 32. Todd KH, Samaroo N, Hoffman JR: Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 269:1537–1539, 1993. 33. Clarke EB, et al: Pain management knowledge, attitudes, and clinical practice: The impact of nurses; characteristics and education. J Pain Symptom Manage 11: 18–31, 1996. 34. Jairath N, Kowal N: Patient expectations and anticipated responses to postsurgical pain. Journal of Holistic Nursing 17:184–196, 1999. 35. Ferrell B, Torry AT, Glick OJ: The use of therapeutic massage as a nursing intervention to modify anxiety and the perception of cancer pain. Cancer Nurs 16:93–101, 1993. 36. Yeager KA, et al: Differences in pain knowledge and perception of the pain experience between outpa-

tients with cancer and their family caregivers. Oncol Nurs Forum 22: 1235–1241, 1995. 37. Miaskowski C, et al: Assessment of patient satisfaction utilizing the American Pain Society’s quality assurance standards on acute and cancer-related pain. J Pain Symptom Manage 9:5–11, 1994. 38. Ward SE, Gordon D: Application of the American Pain Society quality assurance standards. Pain 56:299–306, 1994. 39. Von Roenn HH, et al: Physician attitude and practice in cancer pain management: A survey from the Eastern Cooperative Oncology Group. Ann Intern Med 119:121–126, 1993. 40. Ward SE, Gordon D: Patient satisfaction and pain severity as outcomes in pain management: A longitudinal view of one setting’s experience. J Pain Symptom Manage 11:242–251, 1996. 41. Sherwood GD, et al: Qualitative assessment of hospitalized patients’ satisfaction with pain management. Res Nurs Health 23:486– 495, 2000

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