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Feeling No Pain.
Bogner MS. AHRQ WebM&M [serial online]. July 2003.
Following hysterectomy, a patient-controlled analgesia pump is mistakenly continued in a woman suffering an adverse reaction to morphine, noticed only when her respiratory status set off an alarm.
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Resource Type
Commentary
Setting of Care
General Hospitals
Target Audience
Health Care Providers
Non-Health Care Professionals
Clinical Area
Gynecology
Surgery
Nursing
Safety Target
Medication Errors/Preventable Adverse Drug Events
Opiates/Narcotics
Error Types
Noncognitive Errors ("Slips & Lapses")
Latent Errors
Approach to Improving Safety
Legal and Policy Approaches
Error Analysis
Provider-Patient Communication
Education and Training
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)