Reports of epidural infusion errors.

In the first case, a post-operative patient was prescribed fentanyl 2 mcg/mL with bupivacaine 0.125% by epidural infusion for pain management. The infusion rate ordered was 10 mL/hour. Ketorolac 30 mg intravenously was also prescribed for this patient. A student nurse ‘piggybacked’ a 50 mL minibag containing ketoralac to the main IV line which did not have an infusion pump. She then mistakenly adjusted the flow rate of the epidural infusion pump. The flow rate was set to infuse 150 mL/hour in order to deliver 50 mL in 20 minutes. After 20 minutes, the student nurse returned to the patient and noticed that the minibag containing ketoralac had not been administered. She checked to ensure the line was not blocked and once again reset the epidural infusion pump rate to deliver 150 mL/hr. After another 20 minutes, the patient, having by this time received 100 mL fentanyl/bupivicaine, experienced a respiratory arrest. Fortunately, the patient was resuscitated successfully.