Drug overdose due to malfunction of a patient-controlled analgesia machine: A case report / 대한마취과학회지
Korean Journal of Anesthesiology
;
: 272-275, 2013.
Article
in English
| WPRIM
| ID: wpr-49129
ABSTRACT
Patient-controlled analgesia (PCA) provides excellent pain control and high stability, thereby minimizing the incidence of adverse effects. However, one of our patients experienced respiratory depression and hypotension within 30 minutes of initiation of PCA therapy. We discovered that machine malfunction caused continuous activation of the PCA button, resulting in a drug overdose. The PCA machine was sent to the manufacturer, who found an electrical short in the PCA button. All PCA units of the same make and model were immediately removed from hospitals and replaced with redesigned units without defects in the PCA button. We have used the improved machines without any problems. The purpose of this report is to raise awareness of this type of malfunction in PCA units in order to help prevent adverse events in the future.
Full text:
Available
Index:
WPRIM (Western Pacific)
Main subject:
Respiratory Insufficiency
/
Passive Cutaneous Anaphylaxis
/
Incidence
/
Analgesia, Patient-Controlled
/
Drug Overdose
/
Hypotension
Type of study:
Incidence study
/
Prognostic study
Limits:
Humans
Language:
English
Journal:
Korean Journal of Anesthesiology
Year:
2013
Type:
Article
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