Virginia Hospital Accidentally Kills Patient

stevierae · Dec 19, 2003

I just don't see how you can "accidentally" program a pump with the wrong dose of narcotic.

I used to teach both Curlin and Horizon pumps. On those pumps, it is virtually IMPOSSIBLE to put in a dosage dangerously outside of the therapeutic range--all kinds of little "bells and whistles" go off to alert you as to the danger of what you are attempting to do.

Even if you DELIBERATELY try to override the setting for the therapeutic range, and INTENTIONALLY enter a dosage outside the usual parameters, you still get all kinds of alarms and screen prompts that essentially say "ARE YOU SURE YOU WANT TO DO THIS??!!!"

I'd love to know what brand of pump they were using, and why they exceeded the therapeutic range. This story does not add up.

Geeg · Dec 19, 2003

I still blame the hospitals. They need to provide the safest and most straight forware equipment and adequately train staff to use them.

oramar · Dec 22, 2003

About once or twice a year a MD would decide to put a medical patient on a PCA. They were very difficult to figure out when you did not use them all the time. Sure they inserviced us on them one time a few years earlier, but you have to use that stuff over and over again to be safe with it. I used to have to get a person from a unit where they used them all the time to come and help me program. It seems like these oral oxy drugs are supplanting the IV drugs. They appear to work just as well as IV and IM narcotics. Oh, yes I would like to hear more technical info about what went wrong here. Some of these reports are written by people with no medical background and they really don't get the facts straight.

CCU NRS · Dec 22, 2003

Originally posted by oramar
About once or twice a year a MD would decide to put a medical patient on a PCA. They were very difficult to figure out when you did not use them all the time. Sure they inserviced us on them one time a few years earlier, but you have to use that stuff over and over again to be safe with it. I used to have to get a person from a unit where they used them all the time to come and help me program. It seems like these oral oxy drugs are supplanting the IV drugs. They appear to work just as well as IV and IM narcotics. Oh, yes I would like to hear more technical info about what went wrong here. Some of these reports are written by people with no medical background and they really don't get the facts straight.

This is why we double check when we set them, I was checking a PCA once and the nurse was supposed to set it for PCA of 1mg q 10min and she had done it backwards and set 10mg q 1 min, Morphine so in 5 minutes the Pt could have gotten 50mg MS oops!!!

2ndCareerRN · Dec 22, 2003

Some of these reports are written by people with no medical background and they really don't get the facts straight.

Well, what gave this one away? The fact it is headed as "hospital" kills patients? That is like saying the hospital decided to become some type of killer.

It is the same type of sensational (incorrect) reporting that blames other inantimate objects for death or injury, (cars and guns come right to mind). When all is said and done, it was a person who was the real culprit.

bob

frann · Dec 22, 2003

:kiss

missmakena · Jul 16, 2009

This is why we double check when we set them, I was checking a PCA once and the nurse was supposed to set it for PCA of 1mg q 10min and she had done it backwards and set 10mg q 1 min, Morphine so in 5 minutes the Pt could have gotten 50mg MS oops!!!

I too have seen nurses program pumps with in correct orders. Did we not learn the R's of med delivery in school

allnurses Guide · Jul 17, 2009

the curlin medical 2000 cms, 4000 cms, 6000 cms and painsmartpumps were tested by ecri and were found to have serious defects that can potentially lead to over-infusion.

engineers at ecri found that the pump doors do not fully compress the tubing during operation, which can potentially result in gravity flow, producing over-infusion of medication....

http://thebiomed.com/2008/05/29/curlin-cms-painsmart-pumps-recall-alert/

Home Health Columnist / Guide · Jul 19, 2009

Thanks for updating this 6yo article.