Notcutt W G, Knowles P, Kaldas R
Department of Anaesthesia, James Paget Hospital, Gorleston, Great Yarmouth, Norfolk.
Br J Anaesth. 1992 Jul;69(1):95-7. doi: 10.1093/bja/69.1.95.
Two incidence have occurred in our hospital when a patient-controlled analgesia pump has accidentally delivered the whole contents of the syringe of diamorphine (60 mg) over a period of approximately 1 h. Electrical corruption of the pumps' program has been identified as the probable cause. All pumps of this type have been modified to prevent such occurrences.
我院发生过两起患者自控镇痛泵在约1小时内意外输注完一整支海洛因注射器（60毫克）内容物的事件。已确定泵程序的电子故障是可能原因。所有这种类型的泵都已进行了改装以防止此类事件发生。
