PCA pump error

[BeckysMom1952]

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.

[Isabelle49]

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

[rmelvin]

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

[regularRN]

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]

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]

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]

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

[Isabelle49]

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

[morte, LPN, LVN]

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.

[guineachick, MSN, APRN, NP]

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!

[Isabelle49]

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

[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.

[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.