References
- Committee on Quality of Health Care in America, Institute of MedicineTo err is human: building a safer health system [webpage on the Internet]Washington, DCNational Academies Press2000 Available from: http://www.nap.edu/catalog.php?record_id=9728Accessed February 28, 2014
- Centers for Disease Control and Prevention, National Center for Health StatisticsBirths and deaths: preliminary data for 1998National Vital Statistics Reports199947256
- BrennanTALeapeLLLairdNMIncidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study IN Engl J Med199132463703761987460
- LeapeLLBrennanTALairdNThe nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study IIN Engl J Med199132463773841824793
- PhillipsDPChristenfeldNGlynnLMIncrease in US medication-error deaths between 1983 and 1993Lancet199835191036436449500322
- Committee on Identifying and Preventing Medication Errors and the Board on Health Care ServicesAspdenPWolcottJABootmanJLCronenwettLRPreventing Medication ErrorsQuality Chasm Series2007
- ErnstFRGrizzleAJDrug-related morbidity and mortality: updating the cost-of-illness modelJ Am Pharm Assoc (Wash)200141219219911297331
- Secretary’s Advisory Committee on Regulatory ReformBringing Common Sense to Health Care Regulation: Report of the Secretary’s Advisory Committee on Regulatory Reform2002Washington, DCSecretary’s Advisory Committee on Regulatory Reform Available from: http://www.rwhc.com/papers/DHHS.RRAC.11.21.02.Report.pdfAccessed February 28, 2014
- CullenDJSweitzerBJBatesDWBurdickEEdmondsonALeapeLLPreventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care unitsCrit Care Med1997258128912979267940
- LesterHTritterJQMedical error: a discussion of the medical construction of error and suggestions for reforms of medical education to decrease errorMed Educ200135985586111555223
- RothschildJMLandriganCPCroninJWThe Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive careCrit Care Med20053381694170016096443
- AbramsonNSWaldKSGrenvikANRobinsonDSnyderJVAdverse occurrences in intensive care unitsJAMA198024414158215847420657
- RidleySABoothSAThompsonCMIntensive Care Society’s Working Group on Adverse IncidentsPrescription errors in UK critical care unitsAnaesthesia200459121193120015549978
- HeroutPMErstadBLMedication errors involving continuously infused medications in a surgical intensive care unitCrit Care Med200432242843214758159
- Garrouste-OrgeasMPhilippartFBruelCMaxALauNMissetBOverview of medical errors and adverse eventsAnn Intensive Care201221222339769
- LatifARawatNPustavoitauAPronovostPJPhamJCNational study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settingsCrit Care Med201341238939823263619
- MehrotraRDe GaudioRPalazzoMAntibiotic pharmacokinetic and pharmacodynamic considerations in critical illnessIntensive Care Med200430122145215615536528
- Gonçalves-PereiraJPóvoaPAntibiotics in critically ill patients: a systematic review of the pharmacokinetics of β-lactamsCrit Care2011155R20621914174
- HussainEKaoEMedication safety and transfusion errors in the ICU and beyondCrit Care Clin200521191110 ix15579355
- Kane-GillSWeberRJPrinciples and practices of medication safety in the ICUCrit Care Clin2006222273290 vi16678000
- PronovostPWeastBSchwarzMMedication reconciliation: a practical tool to reduce the risk of medication errorsJ Crit Care200318420120514691892
- Summa-SorginiCFernandesVLubchanskySErrors Associated with IV Infusions in Critical CareCan J Hosp Pharm2012651192622479108
- US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and ResearchGuidance for Industry: Safety Consideration for Product Design to Minimize Medication Errors. Draft Guidance2012Silver Springs, MDUS Food and Drug Administration Available from: http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM331810.pdfAccessed February 28, 2014
- EmmertonLMRizkMFLook-alike and sound-alike medicines: risks and ‘solutions’Int J Clin Pharm20123414822193703
- LambertBLPredicting look-alike and sound-alike medication errorsAm J Health Syst Pharm19975410116111719161623
- Institute for Safe Medication PracticesFailure mode and effects analysis (FMEA): a tool to help guide error prevention efforts [webpage on the Internet]ISMP Medication Safety Alert®2001216 Available from: https://www.ismp.org/tools/FMEA.aspAccessed February 28, 2014
- ScanlanMFrischSNasoduodenal feeding tubes: prevention of occlusionJ Neurosci Nurs19922452562591402149
- SalmonDPontEChevallardHPharmaceutical and safety considerations of tablet crushing in patients undergoing enteral intubationInt J Pharm20134431–214615323299084
- VerrueCMehuysEBousseryKRemonJPPetrovicMTablet-splitting: a common yet not so innocent practiceJ Adv Nurs2011671263221158902
- WilliamsNTMedication administration through enteral feeding tubesAm J Health Syst Pharm200865242347235719052281
- DickersonRNGarmonWMKuhlDAMinardGBrownROVitamin K-independent warfarin resistance after concurrent administration of warfarin and continuous enteral nutritionPharmacotherapy200828330831318294110
- DickersonRNMaishGO3rdMinardGBrownROClinical relevancy of the levothyroxine-continuous enteral nutrition interactionNutr Clin Pract201025664665221139130
- WohltPDZhengLGundersonSBalzarSAJohnsonBDFishJTRecommendations for the use of medications with continuous enteral nutritionAm J Health Syst Pharm200966161458146719667002
- VaagAHandbergALauritzenMHenriksenJEPedersenKDBeck-NielsenHVariation in absorption of NPH insulin due to intramuscular injectionDiabetes Care199013174762404719
- FridAGunnarssonRGüntnerPLindeBEffects of accidental intramuscular injection on insulin absorption in IDDMDiabetes Care198811141453276476
- Dörffler-MellyJde JongeEPontACBioavailability of subcutaneous low-molecular-weight heparin to patients on vasopressorsLancet2002359930984985011897286
- RommersMKVan der LelyNEgbertsTCvan den BemtPMAnti-Xa activity after subcutaneous administration of dalteparin in ICU patients with and without subcutaneous oedema: a pilot studyCrit Care2006103R9316790078
- Cumbo-NacheliGSamavatiLGuzmanJABioavailability of fondaparinux to critically ill patientsJ Crit Care201126434234620889286
- PuthuchearyZARawalJMcPhailMAcute skeletal muscle wasting in critical illnessJAMA2013310151591160024108501
- LatifiRNutritional therapy in critically ill and injured patientsSurg Clin North Am201191357959321621697
- GreenblattDJAllenMDIntramuscular injection-site complicationsJAMA19782406542544671665
- RajGKumarRMcKinneyWPSafety of intramuscular influenza immunization among patients receiving long-term warfarin anticoagulation therapyArch Intern Med199515514152915317605155
- RothschildJMKeohaneCACookEFA controlled trial of smart infusion pumps to improve medication safety in critically ill patientsCrit Care Med200533353354015753744
- LovichMAKinnealleyMESimsNMPeterfreundRAThe delivery of drugs to patients by continuous intravenous infusion: modeling predicts potential dose fluctuations depending on flow rates and infusion system dead volumeAnesth Analg200610241147115316551914
- American Society of Health-System Pharmacists®Standardization of Intravenous Drug ConcentrationsASHP Policy Positions 1982–2013. Policy 1306HawkinsBruce2013 Available from: http://www.ashp.org/DocLibrary/BestPractices/policypositionsonly2013.aspxAccessed February 28, 2014
- BallAMBellamyCJPharmacokinetic alterations in the critically illLankenPNManakerSKohlBAHansonCW3rdThe Intensive Care Unit Manual2nd edPhiladelphia, PAElsevier-Saunders2014
- American Society of Anesthesiologists Task Force on Acute Pain ManagementPractice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain ManagementAnesthesiology2012116224827322227789
- GrissingerMReducing the risk of deadly mixups with epidural and intravenous drugsP T201237843243423091333
- Joint Commission on Accreditation of Healthcare Organizations, USATubing misconnections – a persistent and potentially deadly occurrenceSentinel Event Alert2006361316594109
- World Health OrganizationAvoiding Catheter and Tubing Mis-Connections. Patient Safety Solutions2007GenevaWorld Health Organization Available from: http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution7.pdfAccessed February 28, 2014
- LainerMMannESönnichsenAInformation technology interventions to improve medication safety in primary care: a systematic reviewInt J Qual Health Care201325559059823771745
- CashJJAlert fatigueAm J Health Syst Pharm200966232098210119923309
- LeungAADenhamCRGandhiTKA safe practice standard for barcode technologyJ Patient Saf Epub3102014
- LillyCMThomasEJTele-ICU: experience to dateJ Intensive Care Med2010251162219752038
- KhunlertkitACarayonPContributions of tele-intensive care unit (Tele-ICU) technology to quality of care and patient safetyJ Crit Care2013283315.e1315.e12
- DharmarMKuppermannNRomanoPSTelemedicine consultations and medication errors in rural emergency departmentsPediatrics201313261090109724276844
- MeidlTMWollerTWIglarAMBriertonDGImplementation of pharmacy services in a telemedicine intensive care unitAm J Health Syst Pharm200865151464146918653818
- BoyleTAMahaffeyTMackinnonNJDealHHallstromLKMorganHDeterminants of medication incident reporting, recovery, and learning in community pharmacies: a conceptual modelRes Social Adm Pharm2011719310721397884
- ShannonRCDeMuthJEComparison of medication error detection methods in the long term care facilityConsult Pharm19872148151
- VaradarajanRBarkerKNFlynnEAThomasREComparison of two error-detection methods in a mail service pharmacy serving health facilitiesJ Am Pharm Assoc (2003)200848337137818595822
- WiederholtJBSchommerJCMountJKMcGregorTDBraatzPDThe Wisonsin Pharmacy Self-Inspection Project: an application of Berwick’s theory of continuous improvementAm J Pharm Educ2002662736
- HornEJacobiJThe critical care clinical pharmacist: evolution of an essential team memberCrit Care Med200634Suppl 3S46S5116477202
- KaneSLWeberRJDastaJFThe impact of critical care pharmacists on enhancing patient outcomesIntensive Care Med200329569169812665997
- LeBlancJMSeoane-VazquezECArboTCDastaJFInternational critical care hospital pharmacist activitiesIntensive Care Med200834353854217987280
- SeybertALBartonCMSimulation-based learning to teach blood pressure assessment to doctor of pharmacy studentsAm J Pharm Educ20077134817619648
- SteadmanRHCoatesWCHuangYMSimulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skillsCrit Care Med200634115115716374169
- TuttleRPCohenMHAugustineAJUtilizing simulation technology for competency skills assessment and a comparison of traditional methods of training to simulation-based trainingRespir Care200752326327017328824
- FordDGSeybertALSmithburgerPLKobulinskyLRSamoskyJTKane-GillSLImpact of simulation-based learning on medication error rates in critically ill patientsIntensive Care Med20103691526153120300731
- PrakashVKoczmaraCSavagePMitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy settingBMJ Qual Saf Epub662014
- HofmannDAMarkBAn investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomesPersonnel Psychol2006594847869
- NavehEKatz-NavonTSternZReadiness to report medical treatment errors: the effects of safety procedures, safety information, and priority of safetyMed Care200644211712316434910
- PotylyckiMJKimmelSRRitterMNonpunitive medication error reporting: 3-year findings from one hospital’s Primum Non Nocere initiativeJ Nurs Adm2006367–837037616902361
- SextonJBThomasEJHelmreichRLError, stress, and teamwork in medicine and aviation: cross sectional surveysBMJ2000320723774574910720356
- UribeCLSchweikhartSBPathakDSDowMMarshGBPerceived barriers to medical-error reporting: an exploratory investigationJ Healthc Manag200247426327912221747
- WolfZRSerembusJFMedication errors: ending the blame-gameNurs Manage20043584142444715348967
- LeapeLLWoodsDDHatlieMJKizerKWSchroederSALundbergGDPromoting patient safety by preventing medical errorJAMA199828016144414479801008
- HolmströmARAiraksinenMWeissMWulijiTChanXHLaaksonenRNational and local medication error reporting systems: a survey of practices in 16 countriesJ Patient Saf20128416517623007239
- National Research CouncilPatient safety: achieving a new standard for care [webpage on the Internet]Washington, DCThe National Academies Press2004 Available from: http://www.nap.edu/catalog.php?record_id=10863Accessed February 28, 2014