Drug overdose due to malfunction of a patient-controlled analgesia machine: A case report / 대한마취과학회지
Korean Journal of Anesthesiology
; : 272-275, 2013.
Article
en En
| WPRIM
| ID: wpr-49129
Biblioteca responsable:
WPRO
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.
Palabras clave
Texto completo:
1
Índice:
WPRIM
Asunto principal:
Insuficiencia Respiratoria
/
Anafilaxis Cutánea Pasiva
/
Incidencia
/
Analgesia Controlada por el Paciente
/
Sobredosis de Droga
/
Hipotensión
Tipo de estudio:
Incidence_studies
/
Prognostic_studies
Límite:
Humans
Idioma:
En
Revista:
Korean Journal of Anesthesiology
Año:
2013
Tipo del documento:
Article