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F. Daniel Duffy, MD; Christine K. Cassel, MD; October 2007
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.