Patient-controlled analgesia. A serious incident

Area of Science:

• Anesthesiology
• Medical Device Safety

Background:

• Patient-controlled analgesia (PCA) machines are widely used for pain management.
• A specific PCA pump model experienced a critical failure during clinical use.

Observation:

• A glass syringe disengaged from the PCA machine's drive mechanism, leading to an intravenous overdose of papaveretum (180 mg).
• The patient required and received successful resuscitation following the overdose incident.

Findings:

• The malfunctioning PCA pump had undergone a prior evaluation by a designated test house.
• The specific PCA pump involved in the incident has since been withdrawn from circulation.

Implications:

• Recommendations include positioning PCA equipment at or below the patient's heart level to mitigate risks.
• A call is made for a comprehensive, independent evaluation scheme for all PCA equipment by the Department of Health.