Patient-controlled analgesia. A serious incident.

A patient received a massive overdose of papaveretum intravenously (estimated to be 180 mg) when the glass syringe of a patient-controlled analgesia machine disengaged from the drive mechanism. She was successfully resuscitated. The pump, on loan from the supplier, had passed a brief evaluation by the infusion pump test house designated by the Medical Devices Directorate of the Department of Health; it has since been withdrawn. It is recommended that patient-controlled analgesia equipment should be placed at or below patient heart level. The Department of Health is called on to institute a full, independent evaluation scheme for patient-controlled analgesia equipment.