The California Nurses Assn. filed a complaint with state regulators Thursday alleging that UC Irvine Medical Center has been using faulty pain control pumps that have caused at least five patients to receive an accidental overdose of narcotics.
According to the complaint to the state Department of Public Health, which was made available to The Times, a nurse told supervisors in February that a patient had overdosed because of a malfunction with a Curlin infusion pump; the pumps allow patients to push a button to control how much painkiller they receive while recuperating from surgery.
For The Record
Los Angeles Times Saturday, July 11, 2009 Home Edition Main News Part A Page 4 National Desk 1 inches; 36 words Type of Material: Correction
Pain pumps: An article in Friday's Section A about overdoses delivered by pain pumps at UC Irvine Medical Center said federal regulators began investigating the facility's anesthesiology department in January. The investigation was conducted in 2008.
In that case, the error caused the device to release a dangerous overdose of narcotics all at once. In none of the cases did patients die or suffer lasting injuries.
The hospital confirmed several of the overdoses but disputed the nurses union's allegation that the facility is still using the problematic pumps.
According to the complaint, the hospital knew of the potential dangers.
In a March 6 memo, Lisa Reiser, the hospital's chief nursing officer, wrote to staff that "our current pumps do not have software that is now available to protect patients from an error that would expose them to high levels of narcotics and potentially compromise their respiratory status. We know this and we are rapidly moving forward with Smart pump technology to provide you and our patients another level of protection. In the meantime please know that you as the nurse are that last level of protection."
In an emergency meeting with nurses March 10, according to the complaint, hospital administrators acknowledged that there had been four pump failures over a six-month period, that 50 of the hospital's 158 narcotics pumps had failed mechanical testing and been removed from use, and that the hospital was considering replacing all the pumps.
Then in May, the complaint says, a manager met with nurses to report there had been a fifth pump failure. In that case, the patient had to be transferred to the intensive care unit. While acknowledging that some overdoses occurred, hospital officials said they had determined by conducting a keystroke analysis of the devices that in at least three cases, the cause was human error: Nurses had entered the wrong dosage.
Soon after the emergency meeting, spokesman John Murray said, the hospital purchased new narcotics pumps and is in the process of phasing out the problematic ones and installing more-foolproof software.
