December 2004, Volume 34 Number 12 , p 12 - 14
© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(12) December 2004 p 12–14 Default could lie with de pump [MEDICATION ERRORS: ERRONEOUS PCA]
COHEN, MICHAEL R. RPH, MS, ScD
President of the Institute for Safe Medication Practices
A prescriber ordered patient-controlled analgesia (PCA) for a postoperative patient using the opioid fentanyl according to facility protocol. This called for a 50 mcg/ml concentration, 10 mcg demand doses, a 6 minute lockout, and 20 mcg clinician boluses. The nurse programming the PCA pump accidentally entered the fentanyl concentration as 1 mcg/ml and the demand dose as 0.1 mcg. Another nurse who'd been present but left to take a phone call asked the first nurse to read the settings when she returned, but neither of them detected the errors.
Because the pump contained fentanyl, 50 mcg/ml, and demand doses had been ...