This case involves a fifty-five-year-old female cancer patient who suffered from numerous complications. She remained in good spirits, however, and had the energy to resume near normal activities with sufficient pain medication. She presented to the ER with complaints of severe leg pain and was treated by various physicians who were managing her acute pain. The patient died during the overnight hospital stay. It appears that the cause of death was an overdose of Fentanyl that was ordered and issued at several orders of magnitude above the accepted adult loading dose.