What does everyone have in place for PCA risk mitigation strategies. We currently use Alaris PCA pumps which utilize a typical luer lock syringe along with Epic as our EMR. We recently had an event involving PCAs and are looking to see what other institutions do. We utilize the double check function in Epic but in this situation the nurse did not know what a PCA is and thus was unaware of the double check requirement and since it is a luer lock was able to connect the PCA syringe to the patient's IV line. We use a high alert double check form (HADCF) for other high risk medications such as neuromuscular blocking agents, inhaled epoprostenol, etc... and I worry about potential overuse of the form. We currently do ~ 70-80 PCA patients over a 3 month period. Thanks!