A patient was receiving fentanyl (20 ug/ml, 100 ml bag, intraveneous infusion) via a 6060 pump in the pca mode. At 1400 on the day of the event, the nurse changed the bag. The infusion was started. The nurse came into the room at 1430 for another reason, and the patient "seemed fine". At 1500, the patient's spouse called the nurse into the room, where it was discovered that the pump had a constant "malfunction 9" alarm, and the entire bag of fentanyl had been infused. The set-up was checked, and no leakage was found. Narcan was administered to the patient, and was sent to the surgical icu. As far as the reporter of this incident knows, the patient has returned to pre-incident status.

Preliminary evaluation of the pump indicated that a brass boss on the back of the pump had been broken off, causing conductive flaking to "float around" inside the pump, and to possibly touch the pump's circuitry. The evaluation has not been completed. Should additional significant information become available, a follow-up report will be submitted.

Visual inspection of the pump revealed that the brass boss on the back of the pump had been broken off, causing conductive flaking to float around inside the pump. With the condition of hte pump, operational results cannot be predicted. Pieces of conductive plastic, especially pieces as large as the boss, rattling around inside an electronic piece of equipment have the potential for problematic and irreproducible behavior. The cause of the conductive plastic pieces inside the pump was clearly concluded to be the breakage of the boss. The breakage is in turn caused by the unauthorized reengineering of the mounting of the pump to the lockbox. The acount has been advised to terminate their method for mounting the pump in the lockbox, thus preventing the conductive pieces from being created in the first place.