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PSNet: Patient Safety Network
Journal Article
Commentary

Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].

Syed S; Paul JE; Hueftlein M; Kampf M; McLean RF.

The authors provide a case study involving patient-controlled analgesia (PCA) pump errors that contributed to an accidental morphine overdose. They discuss how the case illustrates that small mistakes can combine to create major problems.