Morphine overdose from error propagation on an acute pain service

Abstract

Purpose: To highlight a case in which multiple errors occurred during programming and administration of analgesia via a patient-controlled analgesia (PCA) pump, and to formulate recommendations on how to avoid such errors in the future. Clinical features:Following lumbar surgery, a 43-yr-old woman was switched from epidural analgesia to a PCA pump. This change was associated with numerous errors at several points of delivery of her care. Errors included incorrect connection of the PCA adapter, incorrect pump programming, and communication lapses which resulted in a morphine overdose and subsequent respiratory arrest. The patient was promptly resuscitated, and she had an uneventful recovery. The event resulted in a complete review of pain management equipment and the training and education of staff using this equipment at our institution. Conclusion:This case highlights how multiple individual errors can combine to result in a serious adverse event. While equipment design was an important factor in this adverse event, human factors played a critical role at multiple levels. Objectif : Présenter un cas où de multiples erreurs sont survenues pendant la programmation et l'administration de l'analgésie autocontrôlée (AAC) et formuler des recommandations sur les moyens d'éviter ces erreurs à l'avenir.

Five-year experience of critical incidents associated with patient-controlled analgesia in an Irish University Hospital

“…Hankin et al [23] reported on device-associated adverse events and found that with PCAs, device malfunction was a major cause of reported adverse events but operator errors were more likely to be associated with adverse outcomes. Various case reports reiterate the adverse outcomes associated with operator/programming errors [24][25][26][27]. Our findings did not have any device malfunction as a cause of CIs.…”

Nurse‐Led Strategies to Improve Patient Safety in Acute Pain Management

“…This route is not without risk as evidenced by local MRAEs reports and repeated errors with preparation and administration of opioid PCA. These issues are universal and have been identified in the published literature (Syed et al 2006;Hicks et al 2008;ISMP 2008). The standardisation of PCA prescriptions, the introduction of a commercially prepared infusate and a single infusion device with imbedded safety parameters have reduced the incidence of PCArelated MRAEs.…”

“…PCA is associated with prescribing, dosing and administration errors (Syed et al 2006;Hicks et al 2008;ISMP 2008) as well as adverse events such as reactions to opioids (Hankin et al 2007). The use of pre-printed prescriptions may reduce the risk of prescribing errors, but programming errors such as the incorrect inputting of the opioid concentration result in what is known as 'inverse relationships' (ISMP 2008) can still occur.…”

Vital sign monitoring with continuous pulse oximetry and wireless clinical notification after surgery (the VIGILANCE pilot study)—a randomized controlled pilot trial

“…Given that the number of patients undergoing surgery annually is about 100 million worldwide, respiratory depression occurs between 1 and 12 million times and it results in about 20, 000 preventable deaths each year [11]. The troublesome aspect of this complication is that it can occur in healthy patients where the family and clinical staff do not anticipate a bad outcome [12].…”