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USP Quality Review

No. 81, Issued September 2004

Selected Cases from MER

1. A male patient was admitted with intractable back pain and a history of arthritis and diabetes and was currently taking oral steroids. The patient was admitted after the pharmacy had closed for the night. For pain control, the patient was ordered morphine PCA with a loading dose of 10 mg, a PCA dose of 4 mg every eight minutes, plus a continuous infusion dose of 2 mg/hour, with a four-hour limit of 130 mg. The patient received 81.7 mg for the first 5.5 hours and 21.3 mg for the next four hours. The patient was found to be unresponsive. A code was called and the patient did not respond and died due to respiratory arrest. The patient had been checked for vitals every hour as per routine. It was discovered after the event that the patient may have had undiagnosed sleep apnea.
2. Settings and concentrations for morphine PCA were ordered per standard protocol. In 1.5 hours, the patient received 4 doses of morphine via the PCA device and was noted as being "talkative, eating, and drinking." Three hours later, a second nurse noted the patient as unresponsive but did not contact the physician. Over the course of the night, the patient received 3 more doses of morphine via the PCA device. Toward the end of the night shift, a third nurse noted that the patient was unresponsive and "gurgling" with lung crackles. The physician was contacted and ordered suctioning, naloxone, and furosemide. The patient's condition improved but again deteriorated later in the day. The patient later expired. When the nurse was cleaning the room, she turned off the PCA device and removed the morphine solution. She noted that the solution in the IV bag did not correlate to the pump. The pump indicated the bag should contain 20 mL with a dose of 8 mg delivered. The nurse calculated that the bag should contain at least 80 mL. The nurse contacted a supervisor, who reviewed the pump settings, and discovered that the pump had been incorrectly programmed to deliver 1 mg/mL instead of 0.1 mg/mL.
3. A PCA-related error occurred in a hospital and it was discovered that the error was not due to a wrong drug, dose, or programming error, but from the overdosage of an opioid as a result of a practice-related error. The nurse, when assessing the patient's pain, would wake the patient to perform the assessment and then would push the PCA pump button on behalf of the patient. The nurse was attempting to assist the patient, but in reality was causing extreme over-sedation and the patient died.
4. A patient was ordered morphine PCA on the evening shift. A nurse mistakenly removed a meperidine PCA syringe from an automatic dispensing machine as an override medication. When the pharmacy reviewed the override medication removals the next morning, the error was discovered. The pump was checked and found to contain a meperidine PCA cartridge, but the dose settings were programmed for morphine. The patient received two doses of 10 mg meperidine instead of 1 mg morphine. In this case, the pump does not read the syringe bar code to verify the correct medication, which might have prevented this error.