Misprogramming PCA Concentration Leads to Dosing Errors
MedSun: Newsletter #29, October 2008
Institute for Safe Medication Practices (ISMP)
ISMP has received a small but concerning number of reports of overdoses with patient controlled analgesia (PCA) due to pump programming errors. Although every aspect in the PCA process has the potential for an error, ISMP is especially concerned about errors related to programming the concentration of the narcotic. Accidentally entering a higher than actual concentration of narcotic in the PCA pump results in the delivery of a lower PCA dose than prescribed. This article offers recommendations to help prevent these errors.
Misprogramming PCA Concentration Leads to Dosing Errors. Institute for Safe Medication Practices. August 28, 2008.