PCA Pump Tubing & Connection Error

A middle-age patient who was admitted to a hospital for surgery was given patient-controlled analgesia (PCA) postoperatively for pain relief. PCA pumps are used to deliver a dose of narcotic, in this case morphine, either continuously and/or when the patient presses a button that allows the machine to do so. These machines have a limit that prevents the patient from getting too much of the drug in a certain time-frame, regardless of how many times he or she presses the button. In order for the PCA pump to work correctly, however, it must first be connected properly with the appropriate IV tubing from the machine to the patient. In this case, the patient was found unresponsive and died while on the PCA machine after surgery when receiving continuous infusions of IV Morphine. So, it was alleged that her death was due to excessive amounts of the drug. Mark Clore was able to show at deposition that the inexperienced nurse who connected the PCA tubing, before the machine was started, dangerously bypassed a safety feature known as a Stopcock valve, thereby allowing the machine to keep pumping more Morphine into the patient than what the doctor had ordered, thus resulting in death. A confidential settlement was reached for the man’s family.


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