Patient Controlled Analgesia (PCA) is frequently used post operatively for pain control. However, PCA use can be dangerous. The Centers for Medicare and Medicaid (CMS) recently proposed a new quality measure describing necessary monitoring of patients receiving opioid PCA infusions. The three factors that must be monitored are respiratory rate, sedation score and pulse oximetry.   However, some would argue that the recommendations do not go far enough, as the time between required documentation must not exceed 2.5 hours and must only be in place for 24 hours. Other groups, such as the Anesthesia Patient Safety Foundation argues monitoring should continuous and not "spot checks", and that capnography should be used, not just oximetry. The Joint Commission's Sentinel Event Alert 49 also raises the issue of sufficient monitoring for these patients. Clearly, this is an important and evolving topic, and we have more work to do in this area.