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PSNet: Patient Safety Network
Journal Article
Commentary

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.

Thyen AB, McAllister RK, Councilman LM. Journal of Patient Safety. 2010;6.

This case report discusses how an error with no lasting patient harm served as a catalyst for organizational efforts on process improvement, protocol review, and safeguard enhancement to ensure safe delivery of epidural analgesia.