Infusion Pump Error Causes Harm

Alan David Kaye, MD, PhD; Cynthia A. Wong, MD

Letter to the Editor:

To the Editor:

We have recently been made aware of a clinical situation in which an excessive volume of local anesthetic was delivered via an epidural infusion pump. The programmed volume was inadvertently set incorrectly (off by a factor of 10 because of a misplaced decimal point). This resulted in permanent paralysis of an otherwise healthy individual. An easy way to decrease the chance of this occurring is to ask your biomedical engineers to program both hard and soft limits on the total hourly volume of drug (and other programable parameters). Additionally, hospital policies should specify which providers are allowed to override soft limits (e.g., ward nurses, anesthetists, anesthesiologists). We hope that each anesthesia provider will evaluate the pumps being utilized for delivery of epidural infusions and make sure that these pumps are utilizing all available safety technology in order to guard against this potentially catastrophic complication. Older pumps without this technology should be replaced.

Alan David Kaye, MD, PhD
Professor and Chairman
Department of Anesthesiology
Director of Pain Services
LSU School of Medicine, New Orleans

Cynthia A. Wong, MD
Professor and Vice Chair
Chief of Obstetrical Anesthesia
Department of Anesthesiology
Northwestern University Feinberg School of Medicine
Chicago, IL 60611

APSF Executive Committee Invites Collaboration

APSF Executive Committee Invites Collaboration From time to time the Anesthesia Patient Safety Foundation reconfirms its commitment of working with all who devote their energies to making anesthesia as safe as humanly possible. Thus, the Foundation invites collaboration from all who administer anesthesia, and all who provide the settings in which anesthesia is practiced, all individuals and all organizations who, through their work, affect the safety of patients receiving anesthesia. All will find us eager to listen to their suggestions and to work with them toward the common goal of safe anesthesia for all patients.