PCA pump error - page 2

Question: Our charge nurse set up a PCA pump with morphine for a new grad. Our policy states she has to set it up with another RN, but this manager just did it herself then had another nurse go in... Read More

  1. by   rmelvin
    Do the PCA pumps malfunction and delivery too much medication even though you programed it correctly?
  2. by   regularRN
    [FONT="Comic Sans MS"]I have never known a PCA pump to malfunction. However, I always have another RN check the pump settings with me and then every hour when I round on the pt. I check again myself. Call me paranoid! :wink2:
  3. by   frann
    my hospital had problems a few years ago, think someone actually died.

    we only carry fentanyl and dilaudid and they are set up so you can't program them incorrectly. Ours are error proof.
    had whole hospital training on new machines. believe our pts have to be on cont. pulse ox.

    but they shouldn't be fired. I believe our hosp policy about firing-can get fired for falsifying records, stealing, but there's no mention of medication mistakes.
  4. by   blondy2061h
    You say the patient got 25mg in one hour. How much was he or she suppose to be able to get? At least for us, 25 mg of morphine in our hour isn't that much (but oncology patients are generally more narcotic tolerant). I recently had a patient on a morphine drip at 125mg/hr with an order that said I could go up to 400mg/hr.
  5. by   Isabelle49
    A PCA pump is a machine and like any machine it is capable of malfunction. You should assess your patient as often as you can to assure no change in mental/respiratory status. Just because a machine is hospital grade, does not mean it can't malfunction. Trusting that a machine can't malfunction can lead to a sense of false security. Always go with your assessment.

    When I worked in NICU we were moving an infant to place him on ECMO (lung bypass) - while bagging the infant across the room to the surgical area, his sats jumped to 100% - before moving him, while he was on the ventilator, his sats were 80 - 85% and often less than that. The Ventilator he was on was malfunctioning. That taught me a big lesson - I never completely trust a machine. The baby did not have to be placed on ECMO and did very well on another ventilator.

    Isabelle
  6. by   Isabelle49
    Quote from Lotte
    [FONT="Comic Sans MS"]I have never known a PCA pump to malfunction. However, I always have another RN check the pump settings with me and then every hour when I round on the pt. I check again myself. Call me paranoid! :wink2:
    Lotte,

    Great that you always have another RN check pump settings. You are very wise to check on your patient every hour. You are not paranoid, you are a good, conscientious nurse - I'd love to have you care for me, if I were the patient.

    It's always good to remember that as a nurse you are the patient's advocate. When patients are on certain medications or in a condition that doesn't allow her/him to voice a problem, they are very vulnerable.

    Lotte, you are also a great patient advocate and you should be proud of it. I don't call it paranoia, for me it's obsessive-compulsive, lol. I've been told that by other nurses too.

    Isbelle
  7. by   morte
    Quote from BeckysMom1952
    Thanks for these replies. The drugs are barcoded but the machines aren't capable of reading them. The patient actually did get that 25 mg of morphine and they only found out when it started beeping because it was empty. He got Narcan of course, but it was a potentially fatal mistake. That's why I wondered whether the MD had a point about firing. Funny though, the nurses involved don't appear humbled at all, they're blaming it on the machine, which is difficult, but we've been using it for years.
    and with this attitude, they will make more mistakes! do not trust them to have your back.
  8. by   guineachick
    What scares me is that she was doing this while "teaching" a new grad!!! Way to show tomorrow's nurses that it's ok to cut corners!
  9. by   Isabelle49
    Quote from BeckysMom1952
    Thanks for these replies. The drugs are barcoded but the machines aren't capable of reading them. The patient actually did get that 25 mg of morphine and they only found out when it started beeping because it was empty. He got Narcan of course, but it was a potentially fatal mistake. That's why I wondered whether the MD had a point about firing. Funny though, the nurses involved don't appear humbled at all, they're blaming it on the machine, which is difficult, but we've been using it for years.

    BeckysMom,

    The first time one of the nurses tries to "blame it on a machine" and a patient dies because of it, he/she is going to get a big wake up call, and it won't be pretty. That nurse will find herself standing alone on an island, defending herself, because the hospital administrators/legal team will not hesitate to point out her/his negligence.

    I am not all about protecting myself and never have been. A nurse's main objective upon entering the profession should be to be the best patient advocate they can be - patient outcome is all that matters in the end.

    Isabelle
  10. by   sweet sunshine
    I work with pcas all the time on my post-surgical floor, pt's can overdose very quickly if not on right settings, I see this as need for retraining and a med error but not firing unless this nurse makes alot of big mistakes on a regular basis.
  11. by   shrinky
    It is amazing that the patient was not harmed. There was an incident at the hospital I work for just before I was hired that involved a peds patient and a PCA and he did not make it. The dose was wrong and was not checked correctly. They are lucky, and though it is an educational opportunity, I agree that some disciplinary action should be taken because policy was not followed by someone in authority. That person should be a role model for the staff and be expected to follow rules also. When I have to change a dose in a home, I call the company that we contract with for IVs and pumps and have a nurse walk through the process with me even though I am comfortable with the pump. It is a safe guard and I would rather be safe than sorry. Enough said, please be careful with these pumps, the nurse involved with the peds patient is still living with what happened.
  12. by   BabyLady
    Quote from maggiofliore
    I learned in my legal class that if you do not receive specific training regarding use of your facility's PCA machine and something goes wrong, you are liable. And, unfortunately, if you did receive education and something goes wrong, you still are liable because having had the training and accepting the opportunity to use the PCA indicates you should be competent in it's operation.

    My legal class makes me very very paranoid now :chuckle

    Does your facility offer training for it? I am curious to see if staff are routinely trained on PCA use.
    You won't be allowed to operate a PCA pump in a facility without being trained on it...too much of a risk to the patient.

    However, the facility policy was clear: Two RN's at the same time...one to set, one to check.

    Doesn't get any clearer than that.

    When you make the choice not to follow protocol and something goes wrong...that is the risk you take...that is why the MD thought both nurses should be fired...but to me, the 2nd nurse wasn't half as guilty as the first...what was the second one supposed to do...refuse to check it?

    If I was the second nurse, I probably would have shut the PCA off and asked for the other nurse to program it and then I would check it.

    However, we are also taught that pumps sometimes malfunction...not only are you responsible for making sure it's programmed right, but responsible for WATCHING to make sure it's dripping at the right rate.

    Because that is what they did before they came up with them there PCA machines (in my best country accent).
  13. by   GraceNotes
    I'm a new grad & uncomfortable with PCAs. I was recently advised by an "experienced" nurse to request doctor's orders for a PCA pump when my patient's pain wasn't well-controlled by hourly PRN IV morphine orders. I just wasn't able to keep up due to high pt load/acuity assignment. I went through a few nurses, starting with the charge nurse, before finding one who knew how to set up the pump & repeated the scenario a couple of days later when it was time to d/c it.

    We had a brief PCA lesson during orientation. I plan to let the manager know (without naming names) that the need for training beyond orientation exists.

    The doctor, I think, feels that if a nurse is suggesting a treatment method she must be knowledgeable...

    This is a good thread. Thanks to all previous posters for sharing your experiences.

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