Patient-controlled analgesia (PCA) is a recognized method of controlling pain when administered by credentialed practitioners. However, serious adverse events can result when unauthorized family members, caregivers, or clinicians administer the analgesia for the patient "by proxy." The Joint Commission summarizes the experience of reported PCA incidents and makes recommendations to minimize them. Note: This alert has been retired effective June 2016. Please refer to the information link below for further details.