title: Patient-controlled analgesia. A serious incident.
abstract: A patient received a massive overdose of papaveretum intravenously (estimated to be 180 mg) when the glass syringe of a patient-controlled analgesia machine disengaged from the drive mechanism. She was successfully resuscitated. The pump, on loan from the supplier, had passed a brief evaluation by the infusion pump test house designated by the Medical Devices Directorate of the Department of Health; it has since been withdrawn. It is recommended that patient-controlled analgesia equipment should be placed at or below patient heart level. The Department of Health is called on to institute a full, independent evaluation scheme for patient-controlled analgesia equipment.
authors.affiliation: Department of Anaesthetics, Guy's Hospital, London.
authors.forename: E R
authors.initials: ER
authors.lastname: Grover
authors.forename: M L
authors.initials: ML
authors.lastname: Heath
mesh_terms: D000293:Adolescent; D016058:Analgesia, Patient-Controlled / Q000295:instrumentation*; D004868:Equipment Failure; D005260:Female; D006801:Humans; D009892:Opium / Q000506:poisoning*; D012131:Respiratory Insufficiency / Q000139:chemically induced*; D012308:Risk Management
chemical_list: D009892:Opium