Pump Programming Errors Research Articles

Symptomatic Treatment of Myelopathy.

This article discusses the effects of myelopathy on multiple organ systems and reviews the treatment and management of some of these effects. Recent advances in functional electrical stimulation, epidural spinal cord stimulation, robotics, and surgical techniques such as nerve transfer show promise in improving function in patients with myelopathy. Ongoing research in stem cell therapy and neurotherapeutic drugs may provide further therapeutic avenues in the future. Treatment for symptoms of spinal cord injury should be targeted toward patient goals. If nerve transfer for upper extremity function is considered, the patient should be evaluated at around 6 months from injury to assess for lower motor neuron involvement and possible time limitations of surgery. A patient with injury at or above the T6 level is at risk for autonomic dysreflexia, a life-threatening condition that presents with elevated blood pressure and can lead to emergent hypertensive crisis. Baclofen withdrawal due to baclofen pump failure or programming errors may also be life-threatening. Proper management of symptoms may help avoid complications such as autonomic dysreflexia, renal failure, heterotopic ossification, and fractures.

Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm.

Significant adverse drug events (ADEs) due to anesthesia infusion pump programming errors were reported at our institution. We incorporated independent two-provider infusion pump programming verification, an evidence-supported intervention, into our anesthesia medication infusion process with a goal of reducing associated ADEs to zero in 2 years. Using the model for improvement, we developed key drivers and interventions and utilized plan-do-study-act (PDSA) cycles. Drivers included education and training, verification process, visual aids, information technology, and safety culture. Interventions included anesthesia provider training, information dissemination, independent two-provider verification process of smart pump programming, verification documentation capability, verification compliance tracking, and visual aids. Our outcome measures were relevant ADEs and near-miss events. Process and balancing measures were the percentage of smart pump programs with independent second verification and delayed case starts due to second provider verification, respectively. During the project period, only one related grade E ADE occurred, and the root cause was not conducting an independent pump programming verification. Thirteen grade B near-miss events were prevented due to independent second verification. Second verification adherence reached 85% and was sustained, and no delayed case starts occurred. With structured quality improvement methods, the process of independent two-provider verification of infusion pump programming during anesthesia can be successfully implemented, and errors in a high-volume setting reduced without negatively affecting case start times. The cultural and organizational factors we report may aid other institutions in gaining project buy-in and sustainment.

Ambulatory chemotherapy: Past, present, and future.

Ambulatory chemotherapy allows the delivery of short and extended chemotherapy infusions through a portable pump from the comfort of patients’ homes. It is essential to offer it for suitable candidates to ensure both their safety and the success of the treatment session. This requires a delicate balance between clinical assessment and patient acceptance.The two main components of this treatment modality are the pump and the access device.There are several pump designs and mechanisms on the market, with the latest being the portable disposable elastomeric one.Clinicians along with a multidisciplinary medical team often decide upon the type of access device; patients are also involved whenever shared decision making is practiced.Despite some reports of pump programming errors or malfunctions, research is underway to find innovative solutions to support its use.

Quality improvement initiative: reducing harmful medication errors in a children’s intensive care unit

Introduction: Medication errors are associated with increased length of stay, high health care costs and are an avoidable cause of morbidity and mortality. Infants and children in the intensive care unit (ICU) are especially vulnerable to medication error-related harm due to their susceptible disease state, frequent administration of high-risk medications and complexities in medication dosing and calculations. In our unit, medication errors were consistently the most common category of reported incidents. Objectives/Aims: The specific aim of the study was to reduce the number of potentially harmful medication errors reported in the children’s intensive care unit by 50%. Methods: A multidisciplinary team was formed, and quality improvement methodology utilised. Medication incident data analysis was conducted and supplemented with observational audit data. The errors identified primarily related to administration, including pump programming errors. Multiple solutions were identified and tested: 1) Development of an innovative medication safety workshop for all new nursing staff 2) Implementation of a systematic daily round to prepare and administer continuous opioid and sedation infusions led by an experienced ICU nurse. 3) Improved access and availability of approved medication resources. The project was supported by multidisciplinary monthly unit-based medication safety meetings. Results: Medication incidents were categorised, pre and post study, utilising the NCC MERP Medication Error Index. The number of serious reported medication errors that caused harm, or required monitoring or intervention to preclude harm, decreased post project commencement by over 30%. Specifically, intravenous pump programming errors significantly reduced post project by over 60%. Analysis of staff confidence attending the workshops also significantly increased in all areas of medication safety. Conclusion: The multidisciplinary project resulted in sustained improvements in medication safety in the children’s ICU. The confidence of new staff in medication safety has increased and the number of serious harmful, or potentially harmful, medication errors has significantly reduced.

Comparative Effectiveness of Patient-Controlled Analgesia for Treating Acute Pain in the Emergency Department

We assess the effectiveness of patient-controlled analgesia in the emergency department (ED). We hypothesized that decline in pain intensity from 30 to 120 minutes after initial intravenous opioid administration is greater in patients receiving morphine by patient-controlled analgesia compared with usual care and would differ by a clinically significant amount. This was a pragmatic randomized controlled trial of patient-controlled analgesia and usual care (opioid and dose at physician's discretion) in 4 EDs. Entry criteria included age 18 to 65 years and acute pain requiring intravenous opioids. The primary outcome was decline in numeric rating scale pain score 30 to 120 minutes postbaseline. Secondary outcomes included satisfaction, time to analgesia, adverse events, and patient-controlled analgesia pump-related problems. We used a mixed-effects linear model to compare rate of decline in pain (slope) between groups. A clinically significant difference between groups was defined as a difference in slopes equivalent to 1.3 numeric rating scale units. Six hundred thirty-six patients were enrolled. The rate of decline in pain from 30 to 120 minutes was greater for patients receiving patient-controlled analgesia than usual care (difference=1.0 numeric rating scale unit; 95% confidence interval [CI] 0.6 to 1.5; P<.001) but did not reach the threshold for clinical significance. More patients receiving patient-controlled analgesia were satisfied with pain management (difference=9.3%; 95% CI 3.3% to 15.1%). Median time to initial analgesia was 15 minutes longer for patient-controlled analgesia than usual care (95% CI 11.4 to 18.6 minutes). There were 7 adverse events in the patient-controlled analgesia group and 1 in the usual care group (difference=2.0%; 95% CI 0.04% to 3.9%), and 11 pump-programming errors. The findings of this study do not favor patient-controlled analgesia over usual ED care for acute pain management.

Impact of Frequent Interruption on Nurses' Patient-Controlled Analgesia Programming Performance.

The purpose was to add to the body of knowledge regarding the impact of interruption on acute care nurses' cognitive workload, total task completion times, nurse frustration, and medication administration error while programming a patient-controlled analgesia (PCA) pump. Data support that the severity of medication administration error increases with the number of interruptions, which is especially critical during the administration of high-risk medications. Bar code technology, interruption-free zones, and medication safety vests have been shown to decrease administration-related errors. However, there are few published data regarding the impact of number of interruptions on nurses' clinical performance during PCA programming. Nine acute care nurses completed three PCA pump programming tasks in a simulation laboratory. Programming tasks were completed under three conditions where the number of interruptions varied between two, four, and six. Outcome measures included cognitive workload (six NASA Task Load Index [NASA-TLX] subscales), total task completion time (seconds), nurse frustration (NASA-TLX Subscale 6), and PCA medication administration error (incorrect final programming). Increases in the number of interruptions were associated with significant increases in total task completion time ( p = .003). We also found increases in nurses' cognitive workload, nurse frustration, and PCA pump programming errors, but these increases were not statistically significant. Complex technology use permeates the acute care nursing practice environment. These results add new knowledge on nurses' clinical performance during PCA pump programming and high-risk medication administration.

Sufentanil sublingual tablet system in the treatment of acute postoperative pain in adults: a profile of its use

The novel sufentanil sublingual tablet system (sufentanil STS; Zalviso®) provides an alternative option to opioid-based intravenous patient-controlled analgesia (IV PCA) for the management of acute moderate to severe postoperative pain in adults in the hospital setting. It overcomes some of the drawbacks associated with opioid-based IV PCA, as the preprogrammed, noninvasive design of the sufentanil STS avoids the risk of pump programming errors and other complications that can occur with IV PCA technology. With each device activation, the patient-controlled sufentanil STS device delivers a sublingual sufentanil 15 μg nanotablet, with patients self-administering to analgesia by varying the interval between doses (minimum between-dose interval 20 min; maximum recommended treatment duration 72 h). Relative to morphine IV PCA, sufentanil delivered by the STS is as effective in relieving post-operative pain with a more rapid onset of analgesia and, according to patient and healthcare professional assessments, provides higher rates of success and overall satisfaction, and is easier to use. Sublingual sufentanil is generally well tolerated, with an adverse event profile typical of that of other opioids and a relatively low risk of respiratory depression.

Optimization of intelligent infusion pump technology to minimize vasopressor pump programming errors

ABSTRACTBackground: There is a lack of data evaluating the impact of hard limit implementation into intelligent infusion pump technology (IIPT). The purpose of this study was to determine if incorporation of vasopressor upper hard limits (UHL) into IIPT increases efficacy of alerts by preventing pump programming errors.Methods: Retrospective review from five hospitals within a single healthcare network between April 1, 2013 and May 31, 2014. A total of 65,680 vasopressor data entries were evaluated; 19,377 prior to hard limit implementation and 46,303 after hard limit implementation. The primary outcome was the percent of effective alerts. The secondary outcome was the proportional dose increase from the soft limit provided.Results: A reduction in alert rate occurred after incorporation of hard limits to the IIPT drug library (pre-UHL 4.7% vs. post-UHL 4.0%) with a subsequent increase in the number of errors prevented as represented by a higher effective alert rate (pre-UHL 23.0% vs. post-UHL 37.3%; p < 0.001). The proportional dose increase was significantly reduced (pre-UHL 188% ± 380%] vs. post-UHL 95% ± 128%; p < 0.001).Conclusions: Incorporation of UHLs into IIPT in a multi-site health system with varying intensive care unit and emergency department acuity increases alert effectiveness, reduces dosing errors, and reduces the magnitude of dosing errors that reach the patient.

Nurses’ Perceived Ease of Use, Mental Effort, and Likelihood of Programming Errors for Four Infusion Pumps

In this study, we report on nurses’ perceptions of the ease of use of four infusion pumps, the mental effort exerted when using the pumps, and the likelihood of programming errors. The key features and operations of the pumps are presented in Table 1. Perceptions were measured after each pump was used in an end-user test. This involved performance of simulated infusion tasks developed by a group of healthcare professionals including nurses and physicians, based on the practical tasks nurses perform with infusion pumps. The tasks included priming and loading the infusion sets, the startup and shut down of the infusion pump, setting basic infusion, and the use of a drug library. The test was conducted in a simulated patient room with a bed, drip stands, and a trolley loaded with solution bottles and administration sets. Sixty registered nurses from five clinical units of three large public hospitals were studied. Perceived ease of use was assessed by seven items adapted from Ginsberg (2005), of which two items (I1 and I2) concerning sets priming and loading (e.g., “Easy to prime and load”), three items (I3, I4, and I5) concerning basic infusion setting (e.g., “Easy to program a basic infusion”), one item (I6) concerning turning on/off the pump (i.e., “Easy to turn on and turn off the pump”), and one item (I7) concerning the usage of drug library (i.e., “Easy to program a drug infusion from drug library”). The items were rated on a 7-point scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). Perceived mental effort was measured by two items (I8 and I9; e.g., “How much mental effort is required when setting up and programming the infusion pump?”), and perceived likelihood of programming errors was examined by one item (I10; i.e., “How likely is it that you would make infusion pump programming errors due to the complex design of the pump?”). These were rated on a 7-point scale ranging from 0 (not at all) to 6 (a great deal). Using a one-way repeated measures analysis of variance, we compared the differences in each of the three perception variables among the four pumps. The correlations among the variables were evaluated using Pearson correlation coefficients. Table 2 shows the means and standard deviations of the variables and the pairwise comparison results. Our results indicated that Pump 3 yielded the highest perceived ease of use, followed by Pump 2, Pump 4, and Pump 1. Pump 3 also achieved a lower perceived mental effort and a lower likelihood of programming errors than the other pumps. Perceived ease of use was negatively correlated with perceived mental effort (rpump1 = -0.53, rpump2 = -0.39, rpump3 = -0.54, rpump4 = -0.30, all p values &lt; 0.05) and perceived likelihood of programming errors (rpump1 = -0.54, rpump2 = -0.34, rpump3 = -0.60, rpump4 = -0.49, all p values &lt; 0.01). It appears that an infusion pump that provides informative feedback on its status and allows simple programming operations is more likely to be perceived as easy to use. Improving the ease of use of the pumps may reduce the mental effort required, and users may perceive they are less likely to make programming errors during use. Critical to the design of effective infusion pumps is the consideration of human factors, which can improve ease of use and simplify the design.

Sublingual Sufentanil: A Review in Acute Postoperative Pain.

The sufentanil sublingual tablet system (SSTS; Zalviso(®)) is a novel patient-controlled analgesia (PCA) device intended to overcome some of the drawbacks of opioid-based intravenous PCA (IV-PCA). Based on the results of three phase III studies, the SSTS has been approved in the EU for the management of acute moderate to severe postoperative pain in adults in a hospital setting. In a head-to-head comparison with morphine, the gold standard for opioid-based IV-PCA, the SSTS was associated with a more rapid onset of analgesia and higher rates of success, based on patient and healthcare professional global assessments of the method of pain control. Patients and healthcare professionals also rated the SSTS as being easier to use and expressed a greater level of overall satisfaction with this device. The SSTS was generally well tolerated, with an adverse event profile typical of that of other opioids and generally similar to that of placebo. By virtue of its preprogrammed, noninvasive design, the SSTS avoids the risk of pump programming errors and other complications (e.g. infections and analgesic gaps) that can occur with IV-PCA technology; it also imposes less restriction on postoperative mobility. As such, the SSTS provides an effective alternative to opioid-based IV-PCA for the management of acute moderate to severe postoperative pain. Future studies should ideally focus on evaluating the relative cost effectiveness of the SSTS and comparing it with other available needle-free PCA modalities.

Hamilton Acute Pain Service Safety Study

Although intravenous patient-controlled analgesia opioids and epidural analgesia offer improved analgesia for postoperative patients treated on an acute pain service, these modalities also expose patients to some risk of serious morbidity and even mortality. Root cause analysis, a process for identifying the causal factor(s) that underlie an adverse event, has the potential to identify and address system issues and thereby decrease the chance of recurrence of these complications. This study was designed to compare the incidence of adverse events on an acute pain service in three hospitals, before and after the introduction of a formal root cause analysis process. The "before" cohort included all patients with pain from February 2002 to July 2007. The "after" cohort included all patients with pain from January 2009 to December 2009. A total of 35,384 patients were tracked over the 7 yr of this study. The after cohort showed significant reductions in the overall event rate (1.47 vs. 2.35% or 1 in 68 vs. 1 in 42, the rate of respiratory depression (0.41 vs. 0.71%), the rate of severe hypotension (0.78 vs. 1.34%), and the rate of patient-controlled analgesia pump programming errors (0.0 vs. 0.08%). Associated with these results, the incidence of severe pain increased from 6.5 to 10.5%. To achieve these results, 26 unique recommendations were made of which 23 being completed, 1 in progress, and 2 not completed. Formal root cause analysis was associated with an improvement in the safety of patients on a pain service. The process was effective in giving credibility to recommendations, but addressing all the action plans proved difficult with available resources.

This Month In: Anesthesiology

This Month In: Anesthesiology

A Systematic Compilation of Reports Published on Opioid-Related Problems

Objectives: This study examined the published literature on case reports of opioid-related problems to create a compendium that might lead to greater awareness and fewer such events. Methods: PubMed, Ovid, and the Cumulative Index to Nursing and Allied Health Literature were searched for case reports. A problem was defined as a healthcare provider’s or patient’s administration of an opioid in an unintended manner resulting in harm. Results: From more than 2,200+ unique articles, 104 met the inclusion criteria. Fentanyl was most implicated. Problems included pump programming errors, patients’ chewing transdermal patches, and pediatric overdosing with an oral droplet dispenser. Of 105 articles, 19 focused on patients with cancer and 86 on patients without cancer. Conclusions: This compendium of opioid-related problems might generate further discussion about how best to reduce their number and morbidity.

A systematic review of the effectiveness of double checking in preventing medication errors

BackgroundMedication errors are unfortunately a constant problem in the medication treatment process. Different interventions are available to reduce or prevent medication errors from reaching the patient. Double checking by two...

A Case Study on the Safety Impact of Implementing Smart Patient-Controlled Analgesic Pumps at a Tertiary Care Academic Medical Center

As with the use of any therapy involving opioids, patient-controlled analgesia (PCA)-related errors can lead to overdose and even death. "Smart" (computerized) pumps have medication safety enhancements, particularly those related to operator errors during administration, to improve overall safety and efficacy. After the occurrence of PCA-related errors that occurred at a tertiary care academic medical center, an analysis of PCA errors was conducted. The introduction of smart pumps was identified as a possible solution, and the medical center adopted the technology in 2006. A study was conducted to investigate the impact of implementation. The study had three primary objectives: (1) to evaluate history logs stored in the smart PCA pumps to characterize the nature of hard and soft stop alerts and identify potential errors that may have been averted, (2) to examine the impact of smart PCA pumps on voluntarily reported PCA therapy-related errors, and (3) to assess nursing perceptions regarding the improvement in safety due to the introduction of smart PCA pumps. The smart pumps potentially prevented 159 errors for the January-June 2007 period; upper hard limits had the most number of alerts, representing avoidance of errors with the greatest potential to be detrimental to the patient. In addition, pump-programming errors due to wrong concentration were eliminated after implementation. Finally, nursing staff perceived smart pumps to be valuable in improving patient safety. Smart PCA pumps had an important positive impact on PCA-related patient safety at the medical center. Other facilities should adopt PCA devices with additional safety features such as bar-code verification of the drug and concentration, as well as dosage limits, to prevent pump-programming errors.

‘Where IT Meets IV’ Integrating Intravenous Infusion Devices With Hospital Information Systems

Tim Vanderveen is vice president of The Center for Safety and Clinical Excellence for CareFusion. E-mail: tim.vanderveen@ carefusion.com Since 2001, “smart” intravenous (IV) infusion pumps with dose-error-reduction software (DERS) have provided hospitals with critical safeguards against potentially fatal pump programming errors and a treasure trove of previously unavailable information on patient safety, IV practices, and quality of care. Nevertheless, IV infusion errors that result in harmful and even fatal adverse drug events (ADEs) are a continuing concern. In response to numerous safety and performance issues with IV infusion pumps, the Association for the Advancement of Medical Instrumentation (AAMI) joined with the Food and Drug Administration (FDA) to host a summit on infusion devices in October 2010. As described in the subsequent conference report, Infusing Patients Safely, a multidisciplinary steering committee was formed to lead a number of working groups in establishing priorities, developing guidelines, and identifying and sharing best practices to improve the safety of IV infusions. Although the agendas of the various working groups are still being developed, the steering committee has adopted a set of future vision statements to help guide it and the working groups in their efforts to make IV infusions safer. The vision boldly describes an attainable state and sets an aggressive national agenda to capitalize on the present opportunities, stating as its mission that “no patient will be harmed from a drug infusion.” The vision starts with establishing wireless connectivity between a hospital’s hundreds of infusion pumps and the hospital’s wireless network. Without this connectivity, other significant advances for improving infusion safety will be impossible to achieve. With this connectivity, an exciting new state of greatly improved safety, quality and productivity can be attained. This article is based on vendor experience in working with hospital partners to implement wireless connectivity for more than 300,000 infusion devices on wireless networks across hospitals of all sizes and levels of complexity. The benefits, challenges and opportunities of integrating infusion devices into hospitals’ health information technology (HIT) systems will be addressed, along with ways to meet the challenges. The potential impact of the continuing convergence of clinical engineering and information technology (IT) will also be covered.

A systematic compilation of reports published on opioid-related problems

This study examined the published literature on case reports of opioid-related problems to create a compendium that might lead to greater awareness and fewer such events. PubMed, Ovid, and the Cumulative Index to Nursing and Allied Health Literature were searched for case reports. A problem was defined as a healthcare provider's or patient's administration of an opioid in an unintended manner resulting in harm. From more than 2200+ unique articles, 104 met the inclusion criteria. Fentanyl was most implicated. Problems included pump programming errors, patients' chewing transdermal patches, and pediatric overdosing with an oral droplet dispenser. Of 105 articles, 19 focused on patients with cancer and 86 on patients without cancer. This compendium of opioid-related problems might generate further discussion about how best to reduce their number and morbidity.

Patient-Controlled Analgesia: Is It Worth the Painful Prescribing Process?

In the last 10 years, the assessment and treatment of pain have become a priority for health care organizations, especially after the introduction of regulatory standards and patient satisfaction surveys directly correlating pain control with a favorable satisfaction score. While much of the focus is on increasing the number of patients receiving adequate pain relief, there has been a subsequent increase in overaggressive attempts to ensure comfort (1). Severe acute pain is best treated with intermittent, intravenous doses of opioids, which allow rapid titration of effect. Appropriately and accurately prescribed patient-controlled analgesia (PCA) is an effective and efficient method of controlling severe acute pain; the risk of oversedation is significantly reduced, and there is considerable potential to improve pain management for patients (2, 3). PCA allows patients to self-administer more frequent but smaller doses of analgesia than the traditional nurse-administered larger and less frequent bolus doses, thus making PCA a favorable choice to comply with standards and patients' goals for comfort. PCA offers advantages especially when protocols are in place to assess the level of pain and sedation; assess the rate, depth, and quality of respirations; perform a preprocedure cognitive assessment; and note whether the patient is opioid tolerant or naive. However, serious unintended consequences such as oversedation, respiratory depression, and undertreated pain may occur from the use of PCA. Contributing factors that lead to these events include improper patient selection, inadequate patient monitoring, pump programming errors, PCA by proxy, patients' self-administration of home analgesics while receiving PCA, imprudent polypharmacy, and insufficient health care team member training or education about medications administered via PCA and their dosing and lockout periods. Adverse events due to one of these many contributing factors are preventable and can be significantly reduced with guidance for treatment team staff, patients, and family members. Numerous adverse event reports totaling in the thousands and a few resulting in patient harm or fatality have occurred since the introduction of PCA (4). In response, the Institute for Safe Medication Practices (ISMP) and the Joint Commission have issued a number of PCA-related safety alerts to health care organizations (2, 3, 5–8). Based on these warnings, many organizations have formed focused, team-based approaches to review PCA-related events and design measures to address the contributing factors leading to these events. Much of the focus is on five areas: patient selection, prescribing errors, staff training, monitoring, and patient education. Developing criteria for selecting appropriate patients to receive PCA is one of the most overlooked but preventable mechanisms to significantly impact events. Well-documented risk factors for oversedation and respiratory depression include opioid-naive status, obesity, age, mental status, and multiple comorbid conditions such as intrinsic lung disease, obstructive sleep apnea (OSA), and renal and hepatic impairment.

Ending Infusion Confusion: Does a virtual intravenous pump educational module enhance transfer of skills to practice?

Programming electronic intravenous (IV) pumps is a technical skill that nursing students typically struggle with throughout the nursing program, and IV pump programming errors may result in medication errors that may cause harm to patients. In response, an online virtual IV pump educational module was developed and trialed in 2008-2009. Results of the evaluation of the module were encouraging and are being used to revise the module. What is not known is whether or not the enhancement of IV pump skills using the virtual IV pump also transfers to the clinical practice setting where the ultimate goal of this project is improved patient safety. It is anticipated that the revised learning module will enhance nursing students' knowledge, skill and confidence in programming and monitoring IV pump infusions.

APA national audit of pediatric opioid infusions

A prospective audit of neonates, infants, and children receiving opioid infusion techniques managed by pediatric acute pain teams from across the United Kingdom and Eire was undertaken over a period of 17 months. The aim was to determine the incidence, nature, and severity of serious clinical incidents (SCIs) associated with the techniques of continuous opioid infusion, patient-controlled analgesia, and nurse-controlled analgesia in patients aged 0-18. The audit was funded by the Association of Paediatric Anaesthetists (APA) and performed by the acute pain services of 18 centers throughout the United Kingdom. Data were submitted weekly via a web-based return form designed by the Document Capture Company that documented data on all patients receiving opioid infusions and any SCIs. Eight categories of SCI were identified in advance, and the reported SCIs were graded in terms of severity (Grade 1 (death/permanent harm); Grade 2 (harm but full recovery and resulting in termination of the technique or needing significant intervention); Grade 3 (potential but no actual harm). Data were collected over a period of 17 months (25/06/07-25/11/08) and stored on a secure server for analysis. Forty-six SCIs were reported in 10 726 opioid infusion techniques. One Grade 1 incident (1 : 10,726) of cardiac arrest occurred and was associated with aspiration pneumonitis and the underlying neurological condition, neurocutaneous melanosis. Twenty-eight Grade 2 incidents (1 : 383) were reported of which half were respiratory depression. The seventeen Grade 3 incidents (1 : 631) were all drug errors because of programming or prescribing errors and were all reported by one center. The overall incidence of 1 : 10,000 of serious harm with opioid infusion techniques in children is comparable to the risks with pediatric epidural infusions and central blocks identified by two recent UK national audits (1,2). Avoidable factors were identified including prescription and pump programming errors, use of concurrent sedatives or opioids by different routes and overgenerous dosing in infants. Early respiratory depression in patients with specific risk factors, such as young age, neurodevelopmental, respiratory, or cardiac comorbidities, who are receiving nurse-controlled analgesia or continuous opioid infusion suggests that closer monitoring for at least 2 h is needed for these cases. As a result of this audit, we can provide parents with better information on relative risks to help the process of informed consent.