Onbedoelde overdosering door derden van patiëntgecontroleerde analgesie bij een kind na een operatie

A 7-year-old boy who had undergone surgery for pectus excavatum received an overdose of morphine. After the operation, he received a combination of continuous intravenous morphine and intravenous patient-controlled analgesia (PCA) in the form of morphine. The parents had repeatedly operated the push-button on the PCA-device because they thought their child was in pain. Thereby they broke the safety loop (negative feedback loop) of the PCA, which ensures that patients who are too sedated to press the button do not press it any further. Respiratory insufficiency occurred due to a high overdose of morphine. Despite the obvious symptoms of overdose, no alarm was raised by the nurses until the onset of apnoea. The patient briefly received artificial respiration, the morphine was stopped and breathing recovered. The following day, intravenous administration of morphine was resumed via the infusion pump.