MEDICATION ERRORS: Default could lie with de pump

December 2004 
Volume 34  Number 12
Pages 12 - 14
  PDF Version Available!

© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(12)             December 2004             p 12–14 Default could lie with de pump [MEDICATION ERRORS: ERRONEOUS PCA]


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 ...

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