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

Abstract

P Pu ur rp po os se e: : To identify the factors that threaten patient safety when using patient-controlled analgesia (PCA) and to obtain an evidencebased estimate of the probability of death from user programming errors associated with PCA.

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.…”

Combining situated Cognitive Engineering with a novel testing method in a case study comparing two infusion pump interfaces

“…To be published in Applied Ergonomics (2016). Woods, 1996;Vicente et al, 2003). Approaching designs using Human Factors engineering has proven to be an effective means to enhance positive performance outcomes, such as fewer errors, less time to performance tasks and lower mental effort (Lin et al, 1998;Syroid et al, 2012).…”

Medical Cyber-Physical Systems

“…But if blood pressure readings remain normal, the more likely cause cause of the problem is a disconnected wire -which is a problem that needs to be fixed but has a much lesser degree of emergency than a heart failure. j) User-Centered Design: Caregiver errors in using medical devices are a major source of adverse events [9], [23]. Undoubtedly, some of these errors are due to stress and overload that caregivers experience daily.…”