MDR report 11682

AT THE END OF SHIFT WHILE CLEARING THE PCA PUMP SOMETHING JUST DIDN'T MAKE SENSE. THE PUMP WAS SET TO DELIVER DEMEROL 10 MG/DOSE WITH A 15 MIN LOCKOUT. THE PT ATTEMPTS FOR THE PAST 12 HRS READ 20 WITH 15 ACTUAL INJECTIONS. HOWEVER, THE RECORDED DOSE GIVEN READ 163.2 MG INSTEAD OF 150 MG (10 MG X 15 INJECTIONS). REVIEW OF THE PCA RECORD FOR THE PREVIOUS THREE SHIFTS ALSO SHOWED DISCREPANCIES. ON FURTHER INVESTIGATION RPTR FOUND THAT WHEN THE PUMP WAS SET UP, THE "CONTINUOUS INFUSION" MODE WAS INADVERTENTLY ACTIVATED AND THAT PT WAS RECEIVING AN ADD'L 1.1 MG/HR; A TOTAL OF 52.8 MG OF DEMEROL OVER TWO DAYS. THIS INCIDENT WAS ALL RPTR NEEDED TO REMEMBER TO CHECK THE "CONTINUOUS INFUSION" MODE AT THE BEGINNING OF SHIFT AND TO ALWAYS MAKE SURE THE NUMBERS MAKE SENSE.