Tenfold PCA Opioid Dosing Error and Delayed Recovery: A Cautionary Case Report

Thursday, November 13, 2025

6:00 PM - 6:08 PM CT

Location: Griffin Hall - Screen 02

Introduction: Patient-controlled analgesia (PCA) is effective for postoperative pain management but at risk of dosing errors, requiring safety measures like lockout parameters to mitigate risk. While focus is often on life-threatening effects like respiratory depression, opioid-related complications including gastrointestinal dysmotility and nausea can be early indicators of overdose [1,2]. We present a case of a 51-year-old opioid-naïve male who experienced a tenfold PCA hydromorphone error after lumbar decompression, causing bowel dysmotility, urinary retention, and delayed recovery.

Submitting Author(s)

JK

Joshua S. Kim, M.D.

Resident Physician
Medical College of Wisconsin
Milwaukee, Wisconsin, United States

Presenting Author(s)

HS

Harmanjot Singh, D.O.

Interventional Pain Fellow
Medical College of Wisconsin, Wisconsin, United States

Co-Author(s)

GK

Gwynne Kirchen, M.D.

Associate Professor
Froedtert Hospital & The Medical College of Wisconsin
Wauwatosa, Wisconsin, United States