[Morphine overdose due to cumulative errors leading to ACP pump dysfunction].

We report the case of a 67-year-female patient treated with a postoperative patient controlled analgesia using an Abbott Gemstar pump for after nephrectomy. In the postanaesthesia care unit, fifteen minutes after connecting with of the pump (which bag contained 100 mg of morphine) to the patient, respiratory arrest occurred. A morphine overdose was caused by uncontrolled delivery of the entire bag contents by free flowing due only to gravity.