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5PSQ-078 Morphine overdose from error infusion rate with intravenous pump: feedback experience and action plan
  1. M Papus,
  2. M Jaffuel,
  3. J Mangavelle,
  4. S Vernardet,
  5. I Lefort
  1. Centre Hospitalier D’ardèche Nord, Pharmacie, Annonay, France


Background Syringe pumps (SP) are a vital tool for administering medicine, especially in palliative care. However, an infusion rate error can be fatal for patients. It is part of the ‘never events’ list (programming error of administration device).

Purpose An infusion rate error (7 mg/h administered versus 0.7 mg/h prescribed) on a SP of morphine in a palliative care patient was reported by the care team. The experience feedback committee (EFC) decided to clarify the error’s circumstances in order to establish an action plan to prevent this error from ever happening again.

Material and methods The adverse event was analysed according to the Association of Litigation and Risk Management (ALARM) method.

The patient’s medical file was investigated and six interviews with health professionals were conducted. We report successive steps of systemic analysis according to the ALARM process. Results of this analysis were presented at an EFC staff meeting and an action plan was established.

Results The immediate cause found was the infusion rate programming error of the SP. Five root causes were identified: SP installation; absence of using bolus function by nurses; lack of training for nurses; interruptions of tasks; and the delay between two infusion rate monitoring of the SP. An action plan has been drafted with seven main actions among which are: creation of simplifying instructions concerning SP’s functions with the help of the biomedical unity and pharmaceutical laboratories, harmonisation of infusion rate monitoring in medicinal protocols and nurses training for intravenous devices used. For each of them a leader has been assigned and a deadline fixed.

Conclusion The infusion rate programming error of the SP is a ‘never event’ which requires the studying of causes and to establish preventive actions. The analysis of this adverse event and its presentation to the EFC led to the setting up of an action plan within our hospital. Such analysis helped to identify care management problems and their systemic causes. Thus it led to corrective measures in order to prevent such events happening again. This multidisciplinary work is part of the quality approach and the patient safety management of our establishment.

References and/or acknowledgements No conflict of interest.

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