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Volumn 50, Issue 4, 2003, Pages 328-332

Programming errors contribute to death from patient-controlled analgesia: Case report and estimate of probability

Author keywords

[No Author keywords available]

Indexed keywords

DIPHENHYDRAMINE; MORPHINE SULFATE;

EID: 0038805213     PISSN: 0832610X     EISSN: None     Source Type: Journal    
DOI: 10.1007/BF03021027     Document Type: Article
Times cited : (143)

References (25)
  • 2
    • 0025719244 scopus 로고
    • Computerized surveillance of adverse drug events in hospital patients
    • Classen DC, Pesotnik SL, Evans RS, Burke JP. Computerized surveillance of adverse drug events in hospital patients. JAMA 1991; 266: 2847-51.
    • (1991) JAMA , vol.266 , pp. 2847-2851
    • Classen, D.C.1    Pesotnik, S.L.2    Evans, R.S.3    Burke, J.P.4
  • 3
    • 0029066463 scopus 로고
    • Incidence of adverse drug events and potential adverse drug events. Implication for prevention
    • Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implication for prevention. JAMA 1995: 274: 29-34.
    • (1995) JAMA , vol.274 , pp. 29-34
    • Bates, D.W.1    Cullen, D.J.2    Laird, N.3
  • 4
    • 0031012726 scopus 로고    scopus 로고
    • The costs of adverse drug events in hospitalized patients
    • Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA 1997; 277: 307-11.
    • (1997) JAMA , vol.277 , pp. 307-311
    • Bates, D.W.1    Spell, N.2    Cullen, D.J.3
  • 5
    • 0028204263 scopus 로고
    • Respiratory depression with patient-controlled analgesia
    • (Editorial)
    • Baxter AD. Respiratory depression with patient-controlled analgesia (Editorial). Can J Anaesth 1994; 41: 87-90.
    • (1994) Can. J. Anaesth. , vol.41 , pp. 87-90
    • Baxter, A.D.1
  • 6
    • 84917307038 scopus 로고    scopus 로고
    • Patient-controlled analgesia
    • (Letter)
    • Doyle DJ, Vicente KJ. Patient-controlled analgesia (Letter). CMAJ 2001; 164: 620.
    • (2001) CMAJ , vol.164 , pp. 620
    • Doyle, D.J.1    Vicente, K.J.2
  • 7
    • 34547951268 scopus 로고    scopus 로고
    • Electrical short circuit as a possible cause of death in patients on PCA machines: Report on an opiate overdose and a possible preventive remedy
    • (Letter)
    • Doyle DJ, Vicente KJ. Electrical short circuit as a possible cause of death in patients on PCA machines: report on an opiate overdose and a possible preventive remedy (Letter). Anesthesiology 2001; 94: 940.
    • (2001) Anesthesiology , vol.94 , pp. 940
    • Doyle, D.J.1    Vicente, K.J.2
  • 8
    • 0031226559 scopus 로고    scopus 로고
    • Abbott PCA Plus II patient-controlled analgesic pumps prone to misprogramming resulting in narcotic overinfusions
    • Emergency Care Research Institute
    • Emergency Care Research Institute. Abbott PCA Plus II patient-controlled analgesic pumps prone to misprogramming resulting in narcotic overinfusions. Health Devices 1997; 26: 389-91.
    • (1997) Health Devices , vol.26 , pp. 389-391
  • 9
    • 0028297101 scopus 로고
    • Respiratory depression associated patient-controlled analgesia: A review of eight cases
    • Etches RC. Respiratory depression associated patient-controlled analgesia: a review of eight cases. Can J Anaesth 1994; 41: 125-32.
    • (1994) Can. J. Anaesth. , vol.41 , pp. 125-132
    • Etches, R.C.1
  • 10
    • 0027403217 scopus 로고
    • Meperidine in patient-controlled analgesia: A near-fatal mishap
    • Geller RJ. Meperidine in patient-controlled analgesia: a near-fatal mishap. Anesth Analg 1993; 76: 655-7.
    • (1993) Anesth. Analg. , vol.76 , pp. 655-657
    • Geller, R.J.1
  • 11
    • 0023941410 scopus 로고
    • Patient-controlled analgesia
    • (Letter)
    • Grey TC, Sweeney ES. Patient-controlled analgesia (Letter). JAMA 1988; 259: 2240.
    • (1988) JAMA , vol.259 , pp. 2240
    • Grey, T.C.1    Sweeney, E.S.2
  • 12
    • 0026582718 scopus 로고
    • Patient-controlled analgesia. A serious incident
    • Grover ER, Heath ML. Patient-controlled analgesia. A serious incident. Anaesthesia 1992; 47: 402-4.
    • (1992) Anaesthesia , vol.47 , pp. 402-404
    • Grover, E.R.1    Heath, M.L.2
  • 13
    • 84873579318 scopus 로고    scopus 로고
    • Evidence builds: Lack of focus on human factors allows error-prone devices
    • Institute for Safe Medication Practices
    • Institute for Safe Medication Practices. Evidence builds: lack of focus on human factors allows error-prone devices. ISMP Medication Safety Alert 1999; 4: 1-2.
    • (1999) ISMP Medication Safety Alert , vol.4 , pp. 1-2
  • 14
    • 0028793494 scopus 로고
    • Overdose of morphine during PCA
    • (Letter)
    • Kwan A. Overdose of morphine during PCA (Letter). Anaesthesia 1995; 50: 919.
    • (1995) Anaesthesia , vol.50 , pp. 919
    • Kwan, A.1
  • 15
    • 0029966299 scopus 로고    scopus 로고
    • Respiratory depression: An adverse outcome during patient controlled analgesia therapy
    • Looi-Lyons LC, Ching FF, Chan VW, McQuestion M. Respiratory depression: an adverse outcome during patient controlled analgesia therapy. J Clin Anaesth 1996; 8: 151-6.
    • (1996) J. Clin. Anaesth. , vol.8 , pp. 151-156
    • Looi-Lyons, L.C.1    Ching, F.F.2    Chan, V.W.3    McQuestion, M.4
  • 16
    • 0026654447 scopus 로고
    • Overdose of opioid from patient-controlled analgesia pumps
    • Notcutt WG, Knowles P, Kaldas R. Overdose of opioid from patient-controlled analgesia pumps. Br J Anaesth 1992; 69: 95-7.
    • (1992) Br. J. Anaesth. , vol.69 , pp. 95-97
    • Notcutt, W.G.1    Knowles, P.2    Kaldas, R.3
  • 17
    • 0028918107 scopus 로고
    • Respiratory arrest with patient-controlled analgesia
    • (Letter)
    • Simes D, Power L, Priestly G. Respiratory arrest with patient-controlled analgesia (Letter). Anaesth Intensive Care 1995; 23: 119-20.
    • (1995) Anaesth. Intensive Care , vol.23 , pp. 119-120
    • Simes, D.1    Power, L.2    Priestly, G.3
  • 18
    • 0032483744 scopus 로고    scopus 로고
    • Incorporating human factors into the design of medical devices
    • (Letter)
    • Weinger MB, Pantiskas C, Wiklund ME, Carstensen P. Incorporating human factors into the design of medical devices (Letter). JAMA 1998; 280: 1484.
    • (1998) JAMA , vol.280 , pp. 1484
    • Weinger, M.B.1    Pantiskas, C.2    Wiklund, M.E.3    Carstensen, P.4
  • 19
    • 0023265299 scopus 로고
    • Mishaps with patient-controlled analgesia
    • White PF. Mishaps with patient-controlled analgesia. Anesthesiology 1987; 66: 81-3.
    • (1987) Anesthesiology , vol.66 , pp. 81-83
    • White, P.F.1
  • 20
    • 0035567897 scopus 로고    scopus 로고
    • Patient safety, potential adverse drug events, and medical device design: A human factors engineering approach
    • (www.idealibrary.com/links/doi/10.1006/jbin.2001.1028/pdf, February 19, 2003)
    • Lin L, Vicente KJ, Doyle DJ. Patient safety, potential adverse drug events, and medical device design: a human factors engineering approach. J Biomed Inform 2001; 34: 274-84. (www.idealibrary.com/links/doi/10.1006/jbin.2001.1028/pdf, February 19, 2003).
    • (2001) J. Biomed. Inform. , vol.34 , pp. 274-284
    • Lin, L.1    Vicente, K.J.2    Doyle, D.J.3
  • 22
    • 0037791133 scopus 로고    scopus 로고
    • Designing a medical device surveillance network report to Congress
    • (www.fda.gov/cdrh/postsurv/medsun.html, February 19, 2002)
    • Gardner S, Flack M. Designing a medical device surveillance network report to Congress. 1999. (www.fda.gov/cdrh/postsurv/medsun.html, February 19, 2002).
    • (1999)
    • Gardner, S.1    Flack, M.2
  • 23
    • 0031920237 scopus 로고    scopus 로고
    • Identifying adverse drug events: Development of a computer-based monitor and comparison with chart review and stimulated voluntary report
    • Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc 1998; 5: 305-14.
    • (1998) J. Am. Med. Inform. Assoc. , vol.5 , pp. 305-314
    • Jha, A.K.1    Kuperman, G.J.2    Teich, J.M.3
  • 24
    • 84917307038 scopus 로고    scopus 로고
    • Patient-controlled analgesia
    • (Letter)
    • McLeskey CH. Patient-controlled analgesia (Letter). CMAJ 2001; 164: 620-1.
    • (2001) CMAJ , vol.164 , pp. 620-621
    • McLeskey, C.H.1
  • 25
    • 0032040921 scopus 로고    scopus 로고
    • Sentinel events: Approaches to error reduction and prevention
    • Joint Commission on Accreditation of Healthcare Organisations
    • Joint Commission on Accreditation of Healthcare Organisations. Sentinel events: approaches to error reduction and prevention. Jt Comm J Qual Improv 1998; 24: 175-86.
    • (1998) Jt Comm. J. Qual. Improv. , vol.24 , pp. 175-186


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.