title: Inserting epidural patient controlled analgesia into a peripheral venous line.
abstract: A case is reported from the Safety Reporting System in Anaesthesia and Resuscitation database. The event occurred in a patient undergoing abdominal surgery in whom an epidural catheter was inserted for analgesia. After the intervention, the patient was transferred to the recovery unit where the patient controlled analgesia (PCA) is programmed. Due to an error, the PCA was connected to a peripheral venous line, which was detected early without harm to the patient. Communication and analysis of this incident served to introduce a new drug delivery protocol through PCA pumps, including the obligation to prescribe the PCA in the electronic system, a dual computerised check immediately before connecting PCA, labelling the medication bag as well as the proximal and distal lines, standardisation of daily visits to patients, and monthly monitoring of results.
mesh_terms: D015360:Analgesia, Epidural; D016058:Analgesia, Patient-Controlled; D000701:Analgesics, Opioid / Q000627:therapeutic use; D000767:Anesthesia, Epidural; D006801:Humans; D059408:Pain Management; D010149:Postoperative Pain / Q000188:drug therapy
chemical_list: D000701:Analgesics, Opioid
keywords: Anaesthesia; Analgesia controlada por paciente; Anestesia; Incidentes críticos (Medicina); Intensive Care Unit; Medical errors; Patient-controlled analgesia; Safety; Seguridad; Unidad de Cuidados Intensivos