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

Correspondence

Programming errors from patient-controlled analgesia

Vincent W. S. Chan, MD FRCPC

Toronto, Ontario

To the Editor:

Patient-controlled analgesia (PCA) programming error is an important patient safety issue as highlighted by Vicente et al.1 Drug overdose and death resulted when morphine 1 mg•mL-1 was set instead of the actual 5 mg•mL-1. I appreciate Dr. Vicente’s reminder and sound recommendations but find the viewpoints somewhat misleading. The article seems to suggest that the Abbott Lifecare 4100 Plus II Infusion Pump is uniquely dangerous because there might be "relatively numerous mortalities ... from user programming errors with this device".1 The authors have singled out the Abbott PCA pump as dangerous without providing objective adverse outcome data for other PCA pumps as comparison. While I acknowledge that the Abbott PCA pump is not foolproof, we must realize that incorrectly entering a lower drug concentration than one actually used can happen with most PCA pumps currently on the market. For example, the factory preset PCA default drug concentration for the Baxter IpumpTM and Sims Deltec CADD® pump is 0 mg•mL-1 and 0.1 mg•mL-1 for the Abbott pump. To my knowledge, only the Alaris PCAM® pump can be programmed to a customized drug delivery profile at this time.

It is important that we read this article in the proper context recognizing that heightened vigilance to prevent human error and drug overdose is needed for all brands of PCA pumps. In the meantime, we wait in anticipation for the next generation of PCA pumps with the promised safety features of bar code reading capability and automatic drug identification.

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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