Catalog Number 2L3104 |
Event Date 10/15/2001 |
Event Type
Malfunction
Patient Outcome
Required Intervention;
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Manufacturer Narrative
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The complaint condition was not confirmed.
The unit met all performance specifications.
There was no retained history in the pump.
Therefore, the pump was evaluated in the pca/basal mode with a dose 1.
0 ml, delay 3 minutes, basal rate 3.
0 ml/hr, 1-hour limit 7 ml.
The customer cable was used.
The test was expected to deliver 9 ml (0.
6372" displacement), and actually delivered 9 ml (0.
635" displacement), which is equal to an error of -0.
35%.
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Event Description
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A pt was admitted to the hosp in 2001 for right hip pain, and was placed on a pcaii pump with morphine for pain control.
Two days later, the pt was to be discharged, but the pt fell and fractured right hip.
The pt was put on traction.
Two days later at 8pm, the pt was found to be lethargic; and at 11pm, the pt was found to be unresponsive and twitching, which was thought to be a pre-existing condition that was exacerbated by the decrease of consiousness.
At that point, the pt was sent to the icu.
It is unknown what medical intervention took place other than sending the pt to the icu.
Three days later, the biomed downloaded the history and printed it, and found that the only history in the pump was for two days ago.
All previous history had been cleared.
The programming of the pump is unknown.
The dr's order was 2 mg every 10 minutes per the pt's file.
The dr on the case did not know definitively what caused the episode, but had deemed it a hypoxic episide.
The account did not know for sure if the pt had been overinfused or not.
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Manufacturer Narrative
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Although the pump has been requested for eval, it has not been received.
Should further significant info become available, a follow-up report will be submitted.
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Search Alerts/Recalls
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