Table 1Examples of averted programming errorsa

LocationDrugVariableInitialReprogrammed
Medical-surgicalHydromorphonePCA dose3 mgDecreased to 1 mg
Medical-surgicalHydromorphoneMaximum limit25 mgDecreased to 10 mg
Medical-surgicalHydromorphoneContinuous dose30 mgDecreased to 1 mg
Medical-surgicalMorphineLoading dose10 mgDecreased to 4 mg
Critical careFentanylContinuous dose300 μgDecreased to 150 μg
Medical-surgicalHydromorphoneMaximum limit200 mgDecreased to 10 mg
Medical-surgicalFentanylPCA dose1 μgIncreased to 50 μg
Critical careMorphineLockout (time)30 minIncreased to 15 min
Critical careMeperidineContinuous dose20 mgDecreased to 10 mg
a

Alerts are not posted until the start key is pressed and programming is completed. All limits are initially set up as “soft” (can be administered as override).

Source: Maddox RR, Williams CK, Oglesby H, et al. Clinical experience with patient-controlled analgesia using continuous respiratory monitoring and a smart infusion system. Am J Health Syst Pharm 2006; 63:157–64. Used with permission.

Alerts are not posted until the start key is pressed and programming is completed. All limits are initially set up as “soft” (can be administered as override).

From: Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period

Cover of Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 4: Technology and Medication Safety)
Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 4: Technology and Medication Safety).
Henriksen K, Battles JB, Keyes MA, et al., editors.

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