Misprogram a PCA Pump? It's Easy!

Vol. 33 No. 10 • October 2008 • P&T® 567 programmed the bolus dose, but because the pump had been set incorrectly at a 1-mcg/mL of the 50-mcg/mL concentration, or 1,000 mcg! About 15 minutes later, the patient was found to be unresponsive and was quickly transferred to the intensive-care unit. The patient died three days later. In this fatal event, the two nurses had been familiar with fentanyl and were well aware of the correct concentration and demand dose that should have been entered into the pump. In fact, the nurse who verified the pump settings mentioned the need for “extra care with fentanyl” to the programming nurse. Both nurses felt certain that the fentanyl concentration had been set at 50 mcg/mL and the demand dose at 10 mcg. This might well have been the case initially, at least for the concentration. During an investigation of these events, the hospital was informed that the pumps could automatically default to an earlier setting if no one confirmed the current setting by pressing “enter” within a short period of time. As such, the nurse could have initially entered the correct concentration but then neglected to press the “enter” key within the allotted time. As a consequence, the setting could have returned to a prior setting on the scroll of numbers—1 mcg/mL for the concentration. Failures in the system of doublechecks also played a role in both fatalities. Even though the hospital required two nurses to confirm PCA pump settings, the policy did not clarify that the double-checks should be performed independently, with one nurse setting the pump and another nurse independently checking the patient, drug, and settings against the orders. Finally, the pump manufacturer had not alerted hospital staff personnel that they could set default values for PCA drugs by locking out the unused range of numbers available.