Nurses say hospital uses faulty devices

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.

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.

The nurses union, Murray said, “is trying to find a smoking gun where none exists.”

“We’re not knowingly allowing any malfunctioning pumps to be used in any patient care areas,” he said. “We dispute their suggestion that we’ve done nothing in response to these incidents. We are taking any piece of equipment out of service when we become aware that it is malfunctioning.”

But the union alleges in its complaint that the hospital has continued using the faulty pumps. Nurses who routinely use them say they have not been upgraded or replaced and continue to put patients at risk, according to the complaint.

“Our assumption was that the pumps were replaced, but obviously there were further problems. I am personally horrified that these pumps were not immediately fixed,” said Beth Kean, director of the University of California Division of the California Nurses Assn. “Regardless of what a nurse puts in, the pumps should never empty their entire content into the patient.”

The complaint also alleges that hospital administrators failed to report the overdoses to state regulators.

Murray, however, said the hospital was not required to report the incidents because the law mandates that only incidents that result in death or serious harm be disclosed.

“None of them fit that requirement,” he said. “But we did take steps to get to the bottom of it.”

Kean disputed that, calling overdoses severe compromises of patient safety.

“Any time that there is an overdose of a narcotic, that is a serious incident,” she said. “When you overdose on narcotics, basically you stop breathing.”

The complaint is the latest to raise questions about patient safety at UCI Medical Center. In May, the state Department of Public Health fined the facility $50,000 for two violations that, in one case, led to a patient’s death. In January, federal regulators began investigating problems in the anesthesiology department. And in 2005, the hospital shut down its liver transplant program after more than 30 people had died awaiting livers.

State regulators said they would investigate the union’s allegations about the pumps.

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