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Canadian Journal of Anesthesia 50:328-332 (2003)
© Canadian Anesthesiologists' Society, 2003
General Anesthesia

Programming errors contribute to death from patient-controlled analgesia: case report and estimate of probability

[Des erreurs de programmation en cause dans un décès lié à l’analgésie auto-contrôlée : une étude de cas et une estimation de la probabilité]

Kim J. Vicente, PhD*,{dagger},{ddagger},§,¶, Karima Kada-Bekhaled, MA{dagger}, Gillian Hillel, BASc{dagger},{ddagger}, Andrea Cassano{dagger} and Beverley A. Orser, MD||

* From the Department of Aeronautics and Astronautics, Massachusetts Institute of Technology, Massachusetts, USA;
{dagger} the Cognitive Engineering Laboratory, the Department of Mechanical and Industrial Engineering;
{ddagger} the Institute of Biomaterials and Biomedical Engineering,
§ the Department of Computer Science,
the Department of Electrical and Computer Engineering; and
|| the Departments of Anesthesia Physiology and Physiology, Sunnybrook and Women’s College Health Science Centre, University of Toronto, Toronto, Ontario, Canada.

Address correspondence to: Dr. Kim J. Vicente, Department of Mechanical & Industrial Engineering, University of Toronto, 5 King’s College Road, Toronto, Ontario M5G 3G8, Canada. Phone: 416-978-7399; E-mail: vicente{at}mie.utoronto.ca, URL: www.mie.utoronto.ca/labs/cel/

Objectif : Déterminer les facteurs qui mettent en danger la sécurité des patients qui utilisent l’analgésie auto-contrôlée (AAC) et obtenir une estimation de la probabilité de décès basée sur des preuves, à partir des erreurs de programmation de l’AAC.

Éléments cliniques : Une femme de 19 ans a donné naissance, par césarienne, à un enfant en bonne santé. Après l’opération, du sulfate de morphine (bolus de 2 mg, période réfractaire de 6 min, limite de 30 mg en 4 h), a été administré avec une pompe à perfusion Abbott Lifecare 4100 Plus II. Une cassette de médicament contenant une solution de 1 mg•mL-1 de morphine n’étant pas disponible, l’infirmière a utilisé une solution plus concentrée (5 mg•mL-1). On a constaté le décès de la patiente 7,5 h après le début de l’AAC. Les échantillons de sang et l’autopsie ont montré une concentration toxique de morphine. La preuve présentée est compatible avec une erreur de programmation de la concentration alors que 1 mg•mL-1 de morphine plutôt que 5 mg•mL-1 était noté. Fondée sur une recherche d’incidents semblables dans la base de données MDR de la Food and Drug Administration et dans d’autres sources, et selon un ensemble de 22 000 000 de données fournies par le fabricant du dispositif, la mortalité résultant d’erreurs de programmation par l’utilisateur a été estimée comme un incident de faible occurrence (de 1 sur 33 000 à 1 sur 338 800), mais relativement important en valeur absolue (de 65 à 667 décès).

Conclusion : Les anesthésiologistes, le personnel infirmier, les ergonomes et les fabricants d’appareils peuvent collaborer à l’amélioration de la sécurité des pompes à AAC en repensant les interfaces-utilisateurs, les cassettes de médicaments et les modes d’emploi hospitalier, ce qui peut réduire les erreurs de programmation et hâter leur détection avant que les patients en souffrent.




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This Article
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Right arrow Articles by Orser, B. A.

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