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PCA pump error

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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 and check it. So, what happened was, she set it up so the patient got 25 mg of morphine in one hour (he survived with no obvious suffering). The charge nurse was not reprimanded, the floor manager decided to use it as an educational experience for the difficulty of the PCA pump. The MD wanted both nurses fired. So my question is, was this just a med error open to education? Or should something more have happened? Should the nurses have been fired?

Thanks for your input.

Thanks for this topic about PCAs.

I don't know the answer to your question - if it is just a med error or if the nurses should be fired. All I can offer is my opinion - that I consider this to

be a situation from which all can learn (an educational opportunity).

I've been doing some reading about PCAs, and some sources explain that these pumps do have risks and that staff who work with the PCAs should be trained re: how to use them. Risks of overdosing, risks because of mis-programming.

Just my opinion - don't fire the nurses, but use this as an opportunity to educate.

fiveofpeep

Specializes in critical care, PACU. Has 2 years experience.

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.

rngolfer53

Has 2 years experience.

I would think that the nurses opened themselves to disciplinary action because they violated the policy/procedure.

Whether that is firing or something less is up to the agency.

Yes, it is an educational opportunity, but that isn't mutually exclusive with discipline.

My :twocents::

Because this incident involved supervisory people, who should know better than to ignore policy/procedures, I would at a minimum suspend them for a week or so. I just find little excuse for what transpired and the risk to the Pt.

rngolfer53

Has 2 years experience.

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.

I occasionally work with PCAs in home settings, usually troubleshooting, or reprogramming r/t a change in orders. I always get out my instructions for the specific model pump and go step-by-step. (Yes, I am a male :D) I've been trained on the ones we use, but I'm still healthily paranoid. I'm not above calling our inpatient hospice facility-- they use PCAs a lot-- to walk me through something if I have the least doubt.

MichelleB34

Specializes in Med-Surg/Pediatrics, Maternity. Has 13 years experience.

I work with PCA's often. I alway take the order in the room when I set up a PCA. Any medicated gtt has to be checked by a second nurse. But most of the time I am picking up a patient from PACU who already has the PCA going. In that case I also check the formula on the PCA against the order because when I take over care of the patient I am responsible for what is going into the patient. I think the nurses involved should receive a med error. This is definitely and opportunity for staff education. The nurses could be subject to disciplinary action for not following hospital policy if that's what management chooses to do. But I don't think this is grounds for firing the nurses involved. Provided these nurses don't have a pattern of making these kinds of mistakes.

We just had an educational workshop on PCA's. We have never used them in our hospital before and we are the only unit using them at this time. We are required to do an Independant double check, where we both have to read the chart, check the pump etc. We don't even have to see each other to do it, but it is not started until both have read the order and done the check. The point of independance is to ensure both nurses obtain the same order.

I don't think these nurses should be fired, warned maybe, but not fired. Med errors happen and it should be an educational opportunity.

The post mentioned the MD wanted the nurses fired. Did anyone check to see if the MD's order was written correctly? I've seen a number of med errors or potential errors that were the MD's fault, and of course the nurse got blamed or yelled at for questioning the order. We will be using a PCA form, to make sure MD's orders are clear and complete.

This will be my first time using PCA machines. I am also curious if your PCA machines are barcoded? Ours are and certain meds will have the order on the screen when the barcode is scanned.

I would hope an incident report was filed and the charge nurse was disciplined for not following p&p but also don't think it should require firing. It is a good educational opportunity also and possibly can point to new facillity policies regarding PCA's.

mama_d, BSN, RN

Specializes in tele, oncology. Has 10 years experience.

I don't necessarily think firing is the answer, but it should at least get a write up IMO. Usually nurses who don't follow P&P on one thing don't on several others, and this helps to create a paper trail of it's a one time error or a consistent issue...and if it's a consistent issue, then further disciplinary action should be eventually taken.

RNperdiem, RN

Has 14 years experience.

I cosigned a PCA the other day and didn't look carefully enough.

When the oncoming nurse and I checked the pump, the error in both dose and time were wrong.

I used to grumble about the form that has the ongoing and offgoing nurse check PCA's and drips together at shift change; not anymore, I was humbled and am still mortified.

The error was minor but real.

I learned a lesson that day that I am sure I will not repeat.

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.

MichelleB34

Specializes in Med-Surg/Pediatrics, Maternity. Has 13 years experience.

At our hospital we have preprinted PCA orders. The doctor picks which drug they want and fills in the doses and the hourly limit. I think the form has the concetration of the drug on it as well. When we program the PCA the first thing we put in is the concentration of the drug. eg Morphine comes 1mg per ml.

Isabelle49

Specializes in Home Health.

The charge nurse should have NEVER set up the PCA pump without having another nurse check her off before connecting to the patient. She was clearly negligent and did not follow policy. Boy, she must have some pretty good connections where you work.

In post anesthesia recovery, one of the nurses set up the PCA pump and I checked it for her. The pump was supposed to have a bag of Demerol in it, but had a bag of Morphine instead. The bags of medication were obtained from a pyxis system (like an atm machine, only it dispenses medication). What happened was when pharmacy filled the machine, they accidently put a bag of PCA morphine in the demerol slot.

When we noticed the problem, pharmacy was notified as well as supervisor. Fortunately the pump had not been connected to the patient when the error was discovered.

Believe it or not, the nurse who originally set up the pump was written up for not noticing that the bag had morphine in it and not demerol. I understand this, but she did follow procedure by having another nurse check.

NEVER, NEVER EVER do something on you own when you are supposed to have a double check, even if you need to get the house supervisor to help you. If you do, one day it will bite you, "you know where". Doing so is wreckless.

Isabelle

Do the PCA pumps malfunction and delivery too much medication even though you programed it correctly?

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:

frann

Specializes in medical/telemetry/IR.

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.

blondy2061h, MSN, RN

Specializes in Oncology. Has 15 years experience.

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.

Isabelle49

Specializes in Home Health.

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

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