Report received of an unrequested bolus dose delivery.
The pump was programmed in the pca only mode to deliver demerol 10mg/ml, with a 10mg pca dose, a 6-minute pt lockout, and a 300mg 4-hour limit.
Therapy was initiated on an unspecified date.
The customer reported that on the date therapy began, the pt had informed the night shift nurse that when the pendant was pushed, the pump would not deliver a dose, but when the pendant was not pushed, the pump would deliver a dose.
The night shift nurse assessed the pump and did not note any unusual pump activity.
At approx 9:00am the next day, the pt informed the day shift nurse that when the pendant was pushed, the pump would not deliver a dose, but when the pendant was not pushed, the pump would deliver a dose.
The nurse pushed the pendant and no delivery occurred.
After an unspecified length of time, the nurse decided to replace the pump, and while taking the pendant from the pt, the pump audibly beeped and delivered an unrequested dose.
The customer reported that the pt did not get more medication than pt should have.
There were no reported adverse pt effects and no medical interventions were required.
Though requested, no additional info was provided.
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