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Canadian Journal of Anesthesia 50:856 (2003)
© Canadian Anesthesiologists' Society, 2003

Correspondence

Programming errors from patient-controlled analgesia

Jonathan D. Lamb, MD FRCPC

Saskatoon, Saskatchewan

To the Editor:

I read with interest this case report of the tragic death of a young woman while receiving patient-controlled analgesia (PCA) post-Cesarean delivery.1 The authors conclude their report with several recommendations. These are all very sensible. The most important recommendation, not mentioned however, concerns the initial nursing assessment of a loudly snoring and unarousable patient while receiving PCA on the ward. This obviously can be an urgent and life-threatening situation which must be dealt with expeditiously. Typically a nursing protocol exists which provides for an immediate and effective response. Did this not exist, or, if so, was it not followed? A different and more favourable outcome might have resulted.

An astute and appropriately trained nurse is the last line of defense for a wide range of untoward and potentially critical situations, such as could arise from a PCA programming error. This, in my opinion, is the paramount message in this tragic case, and not the programming error itself.

Reference

1 Vicente KJ, Kada-Bekhaled K, Hillel G, Cassano A, Orser BA. Programming errors contribute to death from patient-controlled analgesia: case report and estimate of probability. Can J Anesth 2003; 50: 328–32.[Abstract/Free Full Text]


Related articles in CJA:

REPLY
Kim J. Vicente, Karima Kada-Bekhaled, Gillian Hillel, Andrea Cassano, and Beverley A. Orser
CJA 2003 50: 856-857. [Full Text]  




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