Joanna is an experienced nurse. She has worked on the same medical-surgical unit for the past 15 years. During a Saturday night shift, Mrs. Kelly, an 82-year-old patient diagnosed with COPD, complains of abdominal pain. Joanna assesses Mrs. Kelly, who has been a patient on the unit many times in the past. The patient’s vital signs are within normal limits and there is no significant change from past readings. However, Joanna still feels uneasy. Not only does Mrs. Kelly complain of pain, but also she looks sick to Joanna, who senses there is something seriously wrong. Joanna calls the medical resident, who tells her to call back if there are any changes in the vital signs. As the shift progresses, Joanna becomes more convinced that Mrs. Kelly is seriously ill. Although there are no changes in Mrs. Kelly’s vital signs, she calls the resident a second time. The resident yells at Joanna and tells her to stop bothering him. After a couple of hours, Joanna decides to call her supervisor, who checks Mrs. Kelly and encourages Joanna to “get a grip.” Joanna repeatedly checks on Mrs. Kelly, who remains awake throughout the night. The next morning, Joanna reports her assessment to the charge nurse and asks her make sure someone evaluates Mrs. Kelly’s abdominal pain. The charge nurse responds, “Don’t worry about her. If there is anything seriously wrong, she will let us know.” When Joanna returns after 2 days off, she learns that Mrs. Kelly died on Sunday evening of a ruptured abdominal aortic aneurism. Joanna spends that evening crying at the nurses’ station, barely able to take care of her patients.