In Case 5 pain was recorded as 5 or greater on 10 occasions (Figure 2). On seven (70%) occasions no action was taken.Onthree(30%)occasions the dose of acetaminophen due to begiven was administered. The child had an IV infusion of morphine running, prescribed on a sliding scale. The infusion rate was not increased until Day 3. However, after an hour the rate was decreased (to lower than it had been before). At this point the child was prescribed oral morphine every 2 hr. She was given three doses, at 21/4- to 3-hr intervals, without a pain score being recorded. Despite reporting a pain score of 5 or greater, the morphine was administered less fre- quently than it was prescribed (every 3 hr rather than every 2 hr).