May 2006, Volume 36 Number 5 , p 15 - 15
President of the Institute for Safe Medication Practices
A nurse thought she'd programmed an I.V. infusion pump to deliver the sedative-hypnotic agent propofol at 25 ml/hour. Before leaving the patient's room, she checked the pump. Finding that it was delivering 225 ml/hour, she reprogrammed it to deliver the correct dosage. Thinking that pressing on the number “2” key too long may have added the extra numeral, she later tried to re-create the error but couldn't.
This is an example of double key bounce , a rare error that's occurred when a programmed number registered twice although the operator didn't press the button twice. The Alaris SE pump has been involved in known cases, but the problem could affect other pumps too. (Pressing a key twice, known as double keying error , could occur with any type of pump.)
One hospital investigating double key bounce found that the incidence appears directly related to softly or partially ...