A patient who had been hospitalized after suffering a stroke died after being inadvertently injected with fentanyl.

Although the patient's condition improved at first, he later developed dysphagia. After ingesting food and suffering from acute respiratory arrest, the patient was placed on a ventilator during which he was sedated by intravenous (IV) fentanyl injection (10 g/ml) connected to one of the multi-channel 1 Smart infusion pump . Over the next few days, the patient received fentanyl, ranging from 25 to 100 grams per hour, with the dose titrated daily as needed for sedation. A few days later, the patient's doctor terminated the fentanyl infusion in the morning, hoping to extubate the patient that afternoon. The infusion of fentanyl through the pump is turned off, but the infusion container is left in place and remains attached to the patient's fourth line.

Later in the day, the able infusion pump alarm went off, alerting the practitioner that Bollinger's lactated Ringer, which was injected into a different pump channel, was nearing completion. A nurse fills in for the patient's primary nurse who answers the pump's alarm, closes the corresponding pump channel, retrieves a new Lactate Ringer's infusion, connects to the correct pump channel, and programs the correct infusion. However, she had no intention of restarting the fentanyl infusion instead of Ringer's lactated Ringer's. Although the pump alarm went off, the nurse silenced it, believing it had an accident. A night of nurses caring for the patient also failed to notice that fentanyl, not Ringer's lactated Ringer's, was infused. The rate of fentanyl infusion was not disclosed.

A few hours later, the patient's blood pressure had dropped significantly, as well as misperceptions. Although the fentanyl infusion was then rapidly stopped, chronic hypotension caused severe cerebral as well as institutional hypoxia induced by the fentanyl infusion, eventually resulting in the patient being removed from life support after several days.

Recommendations for Safe Practices

Although the Institute for Safe Medication Practices (ISMP) has no additional details on what can be gleaned through the news media other than those, there are several risk reduction strategies that may have prevented this error.

Changed transition verification.  Oncoming nurses are required to verify all infusions assigned to their patients, trace the lines and check the labels for setting up the pump and infusion, and then match each order. The oncoming nurse and the nurse completing her transition should perform this verification process together.

Disconnect and discard all discontinued or held infusion bags/syringes . Discontinued or held infusions should be removed from the pump immediately, disconnected from the patient, and discarded. A stop infusion should not be set up by stopping the infusion pump, keeping the quadrupole attached to the patient and/or hanging from the patient at the bedside. In addition, the tube should be changed to ensure that no residual drug remains that could be inadvertently administered as the tube is used to administer other fluids and drugs.