Infusion pump delivers over-dosage of propofol as a result of missing syringe support.
We describe the malfunction of a common drug infusion pump. The syringe saddle was missing and allowed the syringe barrel to contact the pump case, which decreased the outward displacement of the syringe clamp. Then, the infusion pump falsely detected a smaller syringe size and consequently delivered an increased infusion rate and overdose of propofol to the patient. More commonly, an incorrectly mounted syringe may increase the outward displacement of the syringe clamp so that the infusion pump falsely detects a larger syringe size, with resultant less than expected infusion rate.
Koch
Christian
C
Department of Anesthesiology, University of California-Irvine, Orange, California, USA.
Hollister
Christine
C
Breen
Peter H
PH
D016503:Drug Delivery Systems / Q000009:adverse effects* / Q000295:instrumentation*; D062787:Drug Overdose; D004868:Equipment Failure; D005260:Female; D006801:Humans; D007260:Infusion Pumps / Q000009:adverse effects*; D007262:Infusions, Intravenous; D008875:Middle Aged; D015742:Propofol / Q000009:adverse effects*; D013594:Syringes / Q000009:adverse effects*
D015742:Propofol