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Chiron B et al. - The authors reported an error of syringe rate programming during maintenance of obstetric epidural analgesia and its systemic analysis. The epidural solution included ropivacaine and sufentanil. Despite the 60 mg ropivacaine and the 9.6(mu) g sufentanil doses infused in 45 minutes, no maternal systemic effect was noted. The systemic analysis of this near-miss has revealed a health care system error.

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