Patient‐controlled analgesia

Abstract

SummaryA patient received a massive overdose of papaveretum intravenously (estimated to be 180 mg) when the glass syringe of a patient-controlled analgesia machine disengaged from the drive mechanism. She was successfully resuscitated. The pump, on loan ,from the supplier, had passed a brief evaluation by the infusion pump test house designated by the Medical Devices Directorate qf the Department of Health; it has since been withdrawn. It is recommended that patient-controlled analgesia equipment should be placed at or below patient heart level. The Department of Health is called on to institute a full. independent evaluation scheme for patient-controlled analgesia equipment.

Morphine overdose from error propagation on an acute pain service

“…[6][7][8] Numerous reports of safety hazards and deaths associated with PCA pumps have been reported in the literature since the introduction of this technology. 4,5,[8][9][10][11][12][13][14][15][16][17][18][19][20][21] The following report is a case of respiratory arrest associated with PCA morphine, and illustrates the multiple levels at which errors can occur with PCA administration. Consent was obtained from the patient for use of personal health information in this case report in accordance with our institutional guidelines.…”

Programming errors contribute to death from patient-controlled analgesia: case report and estimate of probability

“…4 Reports of safety hazards and deaths associated with PCA pumps have appeared since this technology was first introduced, and now number in the dozens. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] Therefore, it is important to understand the factors that threaten patient safety with the use of PCA pumps. To contribute to this goal, we report a case where a patient died as a result of a drug overdose.…”

Morphine Overdose from Patient-Controlled Analgesia Pumps

“…In other parts of the world, at least seven serious cases of opioid overdose have been reported [1][2][3][4][5][6][7] . The first fatal case due to equipment failure was reported by Grey and Sweeny in 1988 2 .…”

“…In 1992 another massive overdose of opioid intravenously was reported 4 . The cause of that particular incident was attributed to the disengagement of the glass syringe of a PCA pump from the drive mechanism.…”