Before giving the oxycodone, Beebe scanned the bar code. The system denied permission, adhering to the doctor’s earlier instructions to begin the longer-acting pain meds five hours later. “The computer doesn’t know the patient is in out-of-control pain,” she said.

Still, she didn’t act. “I know if I give the medication, I’m technically giving medication without an order and I can be disciplined,” she said. She watched her patient grimace in pain while she held the pain pill in her hand.