Warning issued for infusion pump
Warning issued for infusion pump
The Institute for Safe Medication Practices (ISMP) has issued a warning about what it calls potential danger from the use of the Abbott Lifecare PCA Plus II Infuser.
The danger involves the dosage of medicine automatically delivered by the machine. In a recent report, the ISMP explains that the Abbott Lifecare PCA Plus II Infuser offers three service modes of operation. One mode, designed to limit choices to specific drugs only, can be used in organizations where only morphine or meperidine is used for PCA. In that mode, the pump sequentially offers a choice of morphine 1 mg/mL, 5 mg/mL, 0.5 mg/mL, and meperidine 10 mg/mL. In a second mode, the same four choices appear sequentially, but additional choices are available for nonspecified drugs. In both of those modes, the initial screen for morphine shows a 1 mg/mL setting that must be acknowledged by the operator by selecting the yes or no function. This is the mode in which all pumps are set before the manufacturer distributes them to customers.
The third mode of operation is intended for use with any narcotic or analgesic with an mg/mL or mcg/mL concentration. In this mode, the practitioner is asked initially if the drug concentration is in mg/mL. If "yes" is selected, the next screen lists an initial setting of 0.1 mg/mL. Nurses must use the arrow keys to change the mg/mL concentration as appropriate to the drug being used. The ISMP says errors have occurred when nurses misread the concentration on the screen as 1 mg/mL, or, from habit, simply pressed the enter function without adjusting the default setting.
"Even if your pumps are not set in this mode of service, errors have occurred when a rented or borrowed pump was unknowingly set in the generic mode or when biomedical engineering staff accidentally changed the mode during the service check," the ISMP reports. "Programming errors have also been reported with the other modes that offer an initial choice of 1 mg/mL concentration for morphine if the 5 mg/mL concentration has been loaded into the pump without altering the concentration settings."
Deaths have been attributed to the mistake with the infusion pump settings, the ISMP says. As a result, it is advising extreme caution: "Hospitals and purchasing groups should not contract with vendors of PCA pumps that default to a setting lower than available drug concentrations. For all PCA, especially with the Abbott pump, it’s important to require documented independent checks. Before infusion, two health professionals should separately check and sign-off on the actual drug syringe and concentration as well as the pump settings for drug, concentration, PCA dose, continuous rate, total dose limit, etc."
The ISMP suggests risk managers alert staff to the possibility of error with the pump. Also, if the 5 mg/mL morphine syringe is available or more potent opiates such as fentanyl or hydromorphone are used, require pulse oximetry to detect the effects of errors quickly to minimize harm.
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