In her 17 years of employment with a large university hospital, Ms. M, a 58-year-old nurse, had worked various shifts in different departments. For the last 9 months, she had been working the night shift and found that the schedule suited her. Her children were now adults and living on their own and Ms. M was divorced, so the night shift did not negatively affect her family. Professionally, she preferred it. In the quiet of the hospital at night, Ms. M felt more autonomous and more connected with her patients, who were often alone (as it was after visiting hours) and frightened. 

One night, at approximately 3 a.m., a patient was brought in from the emergency department (ED) in great pain. Ms. M immediately looked at the patient’s records and orders from the ED physician. The patient, Mr. B, was a 48-year-old man who had been brought into the ED that afternoon complaining of severe abdominal pain, with no obvious cause and no other symptoms such as fever or respiratory distress. 

The pain was hard to manage; notes from the ED indicated that morphine and hydrocodone/paracetamol had proven ineffective, and the ED physician had finally ordered hydromorphone. Even so, the patient’s pain remained severe, and the decision was made to admit him to the hospital for further testing the next day to determine the cause of the pain. 

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The ED physician ordered 1 to 2 mg of hydromorphone administered intravenously no more than every two hours for pain and 12.5 mg of promethazine for nausea. The orders also called for supplemental oxygen as necessary, per the hospital’s protocol. 

Ms. M introduced herself to the patient and began her standard head-to-toe assessment. The assessment would normally include having the patient fill out a database form regarding past medical history, among other information. However, due to Mr. B’s terrible pain, he was only able to fill out a few lines before giving the form back to Ms. M.

“Don’t worry about it,” she told him. “We’ll fill this out later.” 

Ms. M knew that the hospital’s policy was that the patient’s database form should be filled out within the first 24 hours of admission, but clearly the patient’s pain was interfering. Ms. M went over the ED records again and saw that Mr. B had been given 1 mg of hydromorphone two hours earlier in the ED.