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Nurse fined over fatal morphine pump mistake

An Ostrobothnian nurse was sentenced to 60 day-fines after a patient died of a morphine overdose.

Tyhjä sairaalasänky.
Image: Pekka Sipilä / Yle

A nurse has been convicted of involuntary manslaughter after a patient died when she attached a morphine pump set up to deliver twenty times the recommended dose.

The man was being treated in a health centre’s ward and was suffering from severe pain, and died a short time after he was hooked up to the medication.

The nurse pleaded guilty and said that she was not familiar with the model of pump, which she had not used for some nine months at the time of the man’s death.

The woman had prepared the morphine pump for use with other nurses, who also went through the guidelines for its usage numerous times. Nobody, however, went through the separate process for dosage on the machine.

Overdose

At around 12:30pm the nurse attached the pump to the patient, but did not notice that it was set to deliver five millilitres of morphine per hour rather than the five milligrammes the patient should have received.

The man was pronounced dead of a morphine overdose shortly before 2pm.

The Ostrobothnia District Court ruled that the nurse had been careless, but also that there were deficiencies in workplace training on the ward. However she should have been able to use the pump based on her professional training, and that if she was unsure she should have asked for assistance.

The National Supervisory Authority for Health and Welfare, Valvira, released a statement saying that nurses’ training is lacking in the use of medication delivery pumps, and that responsibility for this training lies with their employers.

The 52-year-old nurse was convicted of involuntary manslaughter and given 60 income-related day fines.

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