an inadvertent injection of fentanyl after a patient who had been hospitalized and died of a stroke.

although the patient's condition improved at first, he later developed dysphagia. After sucking food and suffering from acute respiratory arrest, the patient was placed on a ventilator, during which he was sedated via intravenous (IV) fentanyl injection (10 g/ml) connected to a multi-channel 1 on a smart infusion pump. Over the next few days, the patient receives fentanyl, ranging from 25 to 100 grams per hour, with the daily dose titration required for sedation. A few days later, the patient's doctor terminated the fentanyl infusion in the morning, hoping to be able to extubate the patient that afternoon. The pump line for fentanyl injection is closed, but the infusion vessel is left in place and remains connected to the patient's four lines.

Later that day, the infusion pump alarm went away, alerting the practitioner that the Ringer's lactated acid was nearing completion by injecting a different pump channel. A nurse fills the patient's primary nurse to answer the pump alarm, close the corresponding pump track, retrieve the perfusion of new lactate lingeling, connect to the correct pump channel, and program the correct infusion. However, she had no intention of restarting the fentanyl infusion instead of Ringer's lactated Ringer's solution. Despite the fact that the pump alarm went, the nurse silenced it, believing it had an accident. One night the nurse caring for the patient also did not notice that fentanyl, not Ringer's lactated Ringer's, was infused. The rate of fentanyl note is not disclosed.

a few hours later, the patient's blood pressure has dropped significantly, and there is a misconception. Although fentanyl infusions are then quickly discontinued, long-term hypotension causes severe cerebral as well as organ hypoxia caused by fentanyl perfusion, which eventually results in patients being removed from life support a few days later.

recommendations for security practices

although the Institute for Safe Pharmacotherapy Practices (ISMP) has no additional details than what can be gathered through the news media, there are several risk reduction strategies that may have to prevent this error.

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

disconnect and disconnect all aborted or held infusion bags/syringes . Stop or hold the injection should be immediately removed from the pump, cut off the patient, and give up. A stop infusion should not be set up by stopping the infusion pump, keeping it attached to the patient and/or hanging on the patient's four poles at the bedside. In addition, the tube should be changed to ensure that no residual drug may be left as a push given as the tube is used to administer other fluids and drugs.