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Cases & Commentaries
- Web M&M
Chris Vincent, PhD; December 2016
Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.
Patankar MS, Brown JP, Treadwell MD. Aldershot, UK: Ashgate Publishing; 2005. ISBN: 9780754642473.
The authors review the ethical foundations of safety in the aviation, health care, and occupational and environmental health industries. The authors encourage professionals to embrace ethical decision making in supporting their safety work.
ISMP Medication Safety Alert! Acute Care Edition. January 12, 2006;11:1-2.
This article describes problems involving the keys on infusion pumps and includes recommendations to help prevent errors when programming infusion pumps.
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; August 29, 2006.
This news release announces a seizure of infusion pumps that have a "key bounce" defect that could result in over-infusion of medication.