Morphine overdose from error propagation on an acute pain service

Area of Science:

• Anesthesiology
• Patient Safety
• Pharmacology

Background:

• Patient-controlled analgesia (PCA) pumps are widely used for postoperative pain management.
• Effective pain management is crucial for patient recovery and satisfaction.
• Potential for errors exists in the programming and administration of PCA therapy.

Observation:

• A 43-year-old woman experienced a morphine overdose and respiratory arrest following lumbar surgery.
• Errors occurred during the transition from epidural analgesia to PCA pump therapy.
• Specific errors included incorrect PCA adapter connection, pump programming mistakes, and communication failures.

Findings:

• The adverse event resulted from a combination of individual errors at multiple care points.
• Human factors, including communication lapses and programming errors, were critical.
• Equipment design also contributed to the adverse event, necessitating a review.

Implications:

• Highlights the significant risks associated with PCA pump errors.
• Emphasizes the need for robust protocols, comprehensive staff training, and equipment review.
• Underscores the importance of addressing human factors to prevent future medication errors.