Preliminary Steps Selection of a simpler process such as hydromorphone monitoring for MB's case Bring together members of the FMEA team to stipulate the new hydromorphone monitoring process.C3. The three-stage severity point indicates the possibility of adverse consequences, for example, in case of administration of an incorrect dose of hydromorphone and failure to monitor ECG and respiration. The detection point indicates the possibility of detecting what is wrong before it manifests itself, for example what went wrong in M. B's situation would be detected. The point of occurrence indicates that in the possible repetition of the same error, similar results would be observed, meaning that incorrect dosing and inaccurate ECG and respiratory monitoring would give the same results. C4. InterventionsTraining a program emphasizing hydromorphone administrationEstablishing a standard pain assessment and reassessment procedureMandatory training for all staff on the management of high-threshold painEstablishing a standard hydromorphone order set clearly stipulatedTesting interventionsPerform a standard test every three months within the emergency room, which should be accompanied by an assessment of all medical records for hydromorphone