PCA Morphine pump error

PCA pump error, morphine errorThe nurse almost killed my mother

I had just graduated nursing school. Now before that I was an EKG tech, monitor tech and worked in the emergency department as a ward clerk ALL before school so I had a very good understanding of medicine. My mother developed a liposarcoma (fatty tumor) in the chest wall so it was decided that she would have a surgery. Surgery went smoothly but 1 day post-op she was given a PCA (Patient Controlled Analgesia) pump with morphine. Thank God I was in the room and had time to call the anesthesiologist before my mother went into respiratory arrest.

This is what happened: After about 8 hours post-op the PCA line became blocked, so the nurse grabbed a 10cc syringe filled with normal saline and pushed the saline with force into the side port. Unbeknownst to me [I thought she had disconnected the line to my mother] I watched in horror as my mom started slurring and saying the room was spinning and felt “funny”. Needless to say I asked the nurse if she disconnected the line before flushing…this is not ONLY nursing 101 but common sense. Her response was “yes” which was an absolute lie. I went ballistic – screaming and yelling at her that she almost killed my mom with an overdose of morphine. I called the head of anesthesia and had her, the supervisor, and the anesthesiologist ALL in the same room. I was screaming and yelling about the nurse’s stupidity and then lying about it.

After the anesthesiologist half-ass apologized for this “incident”, ALL he said was: “Well, I guess we need to have more inservices on the PCA pump”. What does common sense have to do with inservicing? I requested a different nurse and Mom was discharged home without any other events. There was NO excuse for this period. You have a “supposed” ICU nurse at one of the most well known hospitals pushing normal saline into a PCA pump line connected to the patient that has 100% morphine in the line? I can’t tell you the feeling of helplessness watching my mom get worse… I even knew at that time to get the Narcan (reverses effects of narcotics). Narcan was given after the anesthesiologist was notified.

This is a classic example of nurses not using common sense or paying attention. They are very lucky I did not file a claim but there were no damages. A simple apology by the anesthesiologist and the nurse would have helped but they had this “attitude” that such things are rarities which you and I know is total BS.

The numbers say over 200,000 deaths a year from medical and drug errors? We both know you can probably double those numbers to reflect the true accuracy. I’ll bet what happened to my mom was never documented as a medication error. It is my passion as well to protect the public from stupid nurses and doctors and MORE patient education.

People really need to be educated to be their own advocate.. if I was not in that room at the right time and place my mother may not have survived and gone in to respiratory arrest. It makes me sick to think how many cover ups happen every day. Better communication and transparency is key albeit doctors do not like transparency…it goes against the good ole’ boys club and the God complex for surgeons. That’s my story.
Paul Parks RN
Palm Desert, CA

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