메뉴 건너뛰기




Volumn 32, Issue 7, 2009, Pages 549-559

Patient-controlled analgesia-related medication errors in the postoperative period: Causes and prevention

Author keywords

[No Author keywords available]

Indexed keywords

ANALGESIC AGENT; FENTANYL; OPIATE;

EID: 67649295515     PISSN: 01145916     EISSN: 11791942     Source Type: Journal    
DOI: 10.2165/00002018-200932070-00002     Document Type: Review
Times cited : (50)

References (94)
  • 1
    • 0034847993 scopus 로고    scopus 로고
    • How can information technology improve patient safety and reduce medication errors in children's health care?
    • Kaushal R, Barker KN, Bates DW. How can information technology improve patient safety and reduce medication errors in children's health care? Arch Pediatr Adolesc Med 2001; 155 (9): 1002-7
    • (2001) Arch Pediatr Adolesc Med , vol.155 , Issue.9 , pp. 1002-1007
    • Kaushal, R.1    Barker, K.N.2    Bates, D.W.3
  • 4
    • 0034090289 scopus 로고    scopus 로고
    • Identifying drug safety issues: From research to practice
    • Gandhi TK, Seger DL, Bates DW. Identifying drug safety issues: from research to practice. Int J Qual Health Care 2000; 12 (1): 69-76
    • (2000) Int J Qual Health Care , vol.12 , Issue.1 , pp. 69-76
    • Gandhi, T.K.1    Seger, D.L.2    Bates, D.W.3
  • 5
    • 0036500042 scopus 로고    scopus 로고
    • Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities
    • Flynn EA, Barker KN, Pepper GA, et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 2002; 59 (5): 436-46
    • (2002) Am J Health Syst Pharm , vol.59 , Issue.5 , pp. 436-446
    • Flynn, E.A.1    Barker, K.N.2    Pepper, G.A.3
  • 6
    • 0029957251 scopus 로고    scopus 로고
    • Medication errors. How common are they and what can be done to prevent them?
    • Bates DW. Medication errors. How common are they and what can be done to prevent them? Drug Saf 1996; 15 (5): 303-10
    • (1996) Drug Saf , vol.15 , Issue.5 , pp. 303-310
    • Bates, D.W.1
  • 7
    • 4043084862 scopus 로고    scopus 로고
    • Adverse drug events and medication errors: Detection and classification methods
    • Morimoto T, Gandhi TK, Seger AC, et al. Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care 2004; 13 (4): 306-14
    • (2004) Qual Saf Health Care , vol.13 , Issue.4 , pp. 306-314
    • Morimoto, T.1    Gandhi, T.K.2    Seger, A.C.3
  • 8
    • 33750328584 scopus 로고    scopus 로고
    • Committee on Identifying and Preventing Medication Errors, Washington, DC: The National Academies Press
    • Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, et al. Preventing medication errors: quality chasm series. Washington, DC: The National Academies Press, 2007
    • (2007) Preventing medication errors: Quality chasm series
    • Aspden, P.1    Wolcott, J.2
  • 9
    • 34447095583 scopus 로고    scopus 로고
    • MEDMARX- data report: A chartbook of medication error findings from the perioperative settings from
    • Rockville MD, USP Center for the Advancement of Patient Safety, 2006
    • Hicks RW, Becker SC, Cousins DD. MEDMARX- data report: a chartbook of medication error findings from the perioperative settings from 1998-2005. Rockville (MD): USP Center for the Advancement of Patient Safety, 2006
    • (1998)
    • Hicks, R.W.1    Becker, S.C.2    Cousins, D.D.3
  • 10
    • 85136410059 scopus 로고    scopus 로고
    • Avorn J. Putting adverse drug events into perspective. JAMA 1997; 277 (4): 341-2 11. Avorn J. Dangerous deception-hiding the evidence of adverse drug effects. N Engl J Med 2006; 355 (21): 2169-71
    • Avorn J. Putting adverse drug events into perspective. JAMA 1997; 277 (4): 341-2 11. Avorn J. Dangerous deception-hiding the evidence of adverse drug effects. N Engl J Med 2006; 355 (21): 2169-71
  • 12
    • 0032935169 scopus 로고    scopus 로고
    • Patient-controlled analgesia
    • Etches RC. Patient-controlled analgesia. Surg Clin North Am 1999; 79 (2): 297-312
    • (1999) Surg Clin North Am , vol.79 , Issue.2 , pp. 297-312
    • Etches, R.C.1
  • 13
    • 27244439555 scopus 로고    scopus 로고
    • Patient-controlled analgesia
    • Grass JA. Patient-controlled analgesia. Anesth Analg 2005; 101 Suppl. 5: S44-61
    • (2005) Anesth Analg , vol.101 , Issue.SUPPL. 5
    • Grass, J.A.1
  • 14
    • 0035691604 scopus 로고    scopus 로고
    • Satisfaction with epidural and intravenous patient-controlled analgesia
    • Lebovits AH, Zenetos P, O'Neill DK, et al. Satisfaction with epidural and intravenous patient-controlled analgesia. Pain Med 2001; 2 (4): 280-6
    • (2001) Pain Med , vol.2 , Issue.4 , pp. 280-286
    • Lebovits, A.H.1    Zenetos, P.2    O'Neill, D.K.3
  • 15
    • 0032895715 scopus 로고    scopus 로고
    • Patient-controlled analgesia: An efficient therapeutic tool in the postoperative setting
    • Lehmann KA. Patient-controlled analgesia: an efficient therapeutic tool in the postoperative setting. Eur Surg Res 1999; 31 (2): 112-21
    • (1999) Eur Surg Res , vol.31 , Issue.2 , pp. 112-121
    • Lehmann, K.A.1
  • 16
    • 0034936357 scopus 로고    scopus 로고
    • Safety and efficacy of patient-controlled analgesia
    • Macintyre PE. Safety and efficacy of patient-controlled analgesia. Br J Anaesth 2001; 87 (1): 36-46
    • (2001) Br J Anaesth , vol.87 , Issue.1 , pp. 36-46
    • Macintyre, P.E.1
  • 17
    • 0034898650 scopus 로고    scopus 로고
    • Efficacy and safety of patient-controlled opioid analgesia for acute postoperative pain: A quantitative systematic review
    • Walder B, Schafer M, Henzi I, et al. Efficacy and safety of patient-controlled opioid analgesia for acute postoperative pain: a quantitative systematic review. Acta Anaesthesiol Scand 2001; 45 (7): 795-804
    • (2001) Acta Anaesthesiol Scand , vol.45 , Issue.7 , pp. 795-804
    • Walder, B.1    Schafer, M.2    Henzi, I.3
  • 18
    • 0030823288 scopus 로고    scopus 로고
    • The safety and utilization of patient-controlled analgesia
    • Sidebotham D, Dijkhuizen MR, Schug SA. The safety and utilization of patient-controlled analgesia. J Pain Symptom Manage 1997; 14 (4): 202-9
    • (1997) J Pain Symptom Manage , vol.14 , Issue.4 , pp. 202-209
    • Sidebotham, D.1    Dijkhuizen, M.R.2    Schug, S.A.3
  • 19
    • 0020056361 scopus 로고
    • Patientcontrolled analgesia: A new concept of postoperative pain relief
    • Bennett RL, Batenhorst RL, Bivins BA, et al. Patientcontrolled analgesia: a new concept of postoperative pain relief. Ann Surg 1982; 195 (6): 700-5
    • (1982) Ann Surg , vol.195 , Issue.6 , pp. 700-705
    • Bennett, R.L.1    Batenhorst, R.L.2    Bivins, B.A.3
  • 20
    • 19344370081 scopus 로고    scopus 로고
    • The impact of technology on the analgesic gap and quality of acute pain management
    • Carr DB, Reines HD, Schaffer J, et al. The impact of technology on the analgesic gap and quality of acute pain management. Reg Anesth Pain Med 2005; 30 (3): 286-91
    • (2005) Reg Anesth Pain Med , vol.30 , Issue.3 , pp. 286-291
    • Carr, D.B.1    Reines, H.D.2    Schaffer, J.3
  • 21
    • 37349036129 scopus 로고    scopus 로고
    • Systemrelated events and analgesic gaps during postoperative pain management with the fentanyl iontophoretic transdermal system and morphine intravenous patient-controlled analgesia
    • Panchal SJ, Damaraju CV, Nelson WW, et al. Systemrelated events and analgesic gaps during postoperative pain management with the fentanyl iontophoretic transdermal system and morphine intravenous patient-controlled analgesia. Anesth Analg 2007; 105 (5): 1437-41
    • (2007) Anesth Analg , vol.105 , Issue.5 , pp. 1437-1441
    • Panchal, S.J.1    Damaraju, C.V.2    Nelson, W.W.3
  • 22
    • 42749104447 scopus 로고    scopus 로고
    • Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain
    • CD003348
    • Hudcova J, McNicol E, Quah C, et al. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev 2006; (4): CD003348
    • (2006) Cochrane Database Syst Rev , Issue.4
    • Hudcova, J.1    McNicol, E.2    Quah, C.3
  • 23
    • 67649295963 scopus 로고    scopus 로고
    • The rate and costs attributable to intravenous patient-controlled analgesia errors
    • Meissner B, Hicks RW, Sikirica V, et al. The rate and costs attributable to intravenous patient-controlled analgesia errors. Hosp Pharm 2007; 44 (4): 312-24
    • (2007) Hosp Pharm , vol.44 , Issue.4 , pp. 312-324
    • Meissner, B.1    Hicks, R.W.2    Sikirica, V.3
  • 24
    • 34547136522 scopus 로고    scopus 로고
    • Intravenous patient-controlled analgesia pump and reservoir logistics: Results from a multicenter questionnaire
    • Hutchison R, Anastassopoulos K, Vallow S, et al. Intravenous patient-controlled analgesia pump and reservoir logistics: results from a multicenter questionnaire. Hosp Pharm 2007; 42 (11): 1036-44
    • (2007) Hosp Pharm , vol.42 , Issue.11 , pp. 1036-1044
    • Hutchison, R.1    Anastassopoulos, K.2    Vallow, S.3
  • 25
    • 67649256543 scopus 로고    scopus 로고
    • Vaida AJ, Urbanski B, Grissinger M, et al. PCA Drug Libraries: designing, implementing, and analyzing CQI reports to optimize patient safety [online]. Available from URL: http://www.ismp.org/profdevelopment/PCADrugLib rariesforwebce.pdf [Accessed 2008 May 15]
    • Vaida AJ, Urbanski B, Grissinger M, et al. PCA Drug Libraries: designing, implementing, and analyzing CQI reports to optimize patient safety [online]. Available from URL: http://www.ismp.org/profdevelopment/PCADrugLib rariesforwebce.pdf [Accessed 2008 May 15]
  • 26
    • 1542783234 scopus 로고    scopus 로고
    • Nature of preventable adverse drug events in hospitals: A literature review
    • Kanjanarat P, Winterstein AG, Johns TE, et al. Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm 2003; 60 (17): 1750-9
    • (2003) Am J Health Syst Pharm , vol.60 , Issue.17 , pp. 1750-1759
    • Kanjanarat, P.1    Winterstein, A.G.2    Johns, T.E.3
  • 27
    • 0029066463 scopus 로고
    • Incidence of adverse drug events and potential adverse drug events: Implications for prevention. ADE Prevention Study Group
    • Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. ADE Prevention Study Group. JAMA 1995; 274 (1): 29-34
    • (1995) JAMA , vol.274 , Issue.1 , pp. 29-34
    • Bates, D.W.1    Cullen, D.J.2    Laird, N.3
  • 28
    • 0028903086 scopus 로고
    • Relationship between medication errors and adverse drug events
    • Bates DW, Boyle DL, Vander Vliet MB, et al. Relationship between medication errors and adverse drug events. J Gen Intern Med 1995; 10 (4): 199-205
    • (1995) J Gen Intern Med , vol.10 , Issue.4 , pp. 199-205
    • Bates, D.W.1    Boyle, D.L.2    Vander Vliet, M.B.3
  • 29
    • 0030790808 scopus 로고    scopus 로고
    • Preventable adverse drug events in hospitalized patients: A comparative study of intensive care and general care units
    • Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med 1997; 25 (8): 1289-97
    • (1997) Crit Care Med , vol.25 , Issue.8 , pp. 1289-1297
    • Cullen, D.J.1    Sweitzer, B.J.2    Bates, D.W.3
  • 30
    • 0034493069 scopus 로고    scopus 로고
    • Prevention of adverse drug events: A decade of progress in patient safety
    • Cullen DJ, Bates DW, Leape LL. Prevention of adverse drug events: a decade of progress in patient safety. J Clin Anesth 2000; 12 (8): 600-14
    • (2000) J Clin Anesth , vol.12 , Issue.8 , pp. 600-614
    • Cullen, D.J.1    Bates, D.W.2    Leape, L.L.3
  • 32
    • 0035946697 scopus 로고    scopus 로고
    • Medication errors and adverse drug events in pediatric inpatients
    • Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285 (16): 2114-20
    • (2001) JAMA , vol.285 , Issue.16 , pp. 2114-2120
    • Kaushal, R.1    Bates, D.W.2    Landrigan, C.3
  • 33
    • 0027933477 scopus 로고
    • Factors associated with preventable adverse drug reactions
    • Pearson TF, Pittman DG, Longley JM, et al. Factors associated with preventable adverse drug reactions. Am J Hosp Pharm 1994; 51 (18): 2268-72
    • (1994) Am J Hosp Pharm , vol.51 , Issue.18 , pp. 2268-2272
    • Pearson, T.F.1    Pittman, D.G.2    Longley, J.M.3
  • 34
    • 0034146799 scopus 로고    scopus 로고
    • Incidence and types of adverse events and negligent care in Utah and Colorado
    • Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000; 38 (3): 261-71
    • (2000) Med Care , vol.38 , Issue.3 , pp. 261-271
    • Thomas, E.J.1    Studdert, D.M.2    Burstin, H.R.3
  • 35
    • 0027454282 scopus 로고
    • The Australian Incident Monitoring Study. The 'wrong drug' problem in anaesthesia: An analysis of 2000 incident reports
    • Currie M, Mackay P, Morgan C, et al. The Australian Incident Monitoring Study. The 'wrong drug' problem in anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21 (5): 596-601
    • (1993) Anaesth Intensive Care , vol.21 , Issue.5 , pp. 596-601
    • Currie, M.1    Mackay, P.2    Morgan, C.3
  • 36
    • 67649259742 scopus 로고    scopus 로고
    • 5 Million Lives Campaign. Getting started kit: Prevent harm from highalert medications
    • Institute for Healthcare Improvement, Cambridge MA, Institute for Healthcare Improvement
    • Institute for Healthcare Improvement. 5 Million Lives Campaign. Getting started kit: prevent harm from highalert medications. How-to guide. Cambridge (MA): Institute for Healthcare Improvement, 2006
    • (2006) How-to guide
  • 37
    • 0037316163 scopus 로고    scopus 로고
    • Opioids: A review
    • Chevlen E. Opioids: a review. Curr Pain Headache Rep 2003; 7 (1): 15-23
    • (2003) Curr Pain Headache Rep , vol.7 , Issue.1 , pp. 15-23
    • Chevlen, E.1
  • 38
    • 0036323891 scopus 로고    scopus 로고
    • Clinical pharmacology of opioids for pain
    • Inturrisi CE. Clinical pharmacology of opioids for pain. Clin J Pain 2002; 18 (4 Suppl.): S3-13
    • (2002) Clin J Pain , vol.18 , Issue.4 SUPPL.
    • Inturrisi, C.E.1
  • 39
    • 0031226559 scopus 로고    scopus 로고
    • Abbott PCA Plus II patient-controlled analgesic pumps prone to misprogramming resulting in narcotic overinfusions [hazard report, Health Devices 1997; 26 9-10, 389-91
    • Abbott PCA Plus II patient-controlled analgesic pumps prone to misprogramming resulting in narcotic overinfusions [hazard report]. Health Devices 1997; 26 (9-10): 389-91
  • 40
    • 0343907153 scopus 로고    scopus 로고
    • Human error and patient-controlled analgesia pumps
    • Brown SL, Bogner MS, Parmentier CM, et al. Human error and patient-controlled analgesia pumps. J Intraven Nurs 1997; 20 (6): 311-6
    • (1997) J Intraven Nurs , vol.20 , Issue.6 , pp. 311-316
    • Brown, S.L.1    Bogner, M.S.2    Parmentier, C.M.3
  • 41
    • 85026149207 scopus 로고    scopus 로고
    • Patient-controlled analgesia-eliminating errors
    • Eade DM. Patient-controlled analgesia-eliminating errors. Nurs Manage 1997; 28 (6): 38-40
    • (1997) Nurs Manage , vol.28 , Issue.6 , pp. 38-40
    • Eade, D.M.1
  • 42
    • 0036731286 scopus 로고    scopus 로고
    • Medication safety: PCA pump programming errors continue to cause fatal overinfusions [hazard report]
    • ECRI
    • ECRI. Medication safety: PCA pump programming errors continue to cause fatal overinfusions [hazard report]. Health Devices 2002; 31 (9): 342-6
    • (2002) Health Devices , vol.31 , Issue.9 , pp. 342-346
  • 43
    • 67649298539 scopus 로고    scopus 로고
    • Safety issues with patient-controlled analgesia, part 1: Causes of errors
    • Grissinger M. Safety issues with patient-controlled analgesia, part 1: causes of errors. Pharm Today 2003; 21
    • (2003) Pharm Today , pp. 21
    • Grissinger, M.1
  • 44
    • 67649287167 scopus 로고    scopus 로고
    • Safety issues with patient-controlled analgesia, part 2: How to prevent errors
    • Grissinger M. Safety issues with patient-controlled analgesia, part 2: how to prevent errors. Pharm Today 2003; 16
    • (2003) Pharm Today , pp. 16
    • Grissinger, M.1
  • 45
    • 0038805213 scopus 로고    scopus 로고
    • Programming errors contribute to death from patient-controlled analgesia: Case report and estimate of probability
    • Vicente KJ, Kada-Bekhaled K, Hillel G, et al. Programming errors contribute to death from patient-controlled analgesia: case report and estimate of probability. Can J Anesth 2003; 50 (4): 328-32
    • (2003) Can J Anesth , vol.50 , Issue.4 , pp. 328-332
    • Vicente, K.J.1    Kada-Bekhaled, K.2    Hillel, G.3
  • 46
    • 0035111067 scopus 로고    scopus 로고
    • Patient-controlled analgesia
    • Doyle DJ, Vicente KJ. Patient-controlled analgesia. CMAJ 2001; 164 (5): 620-1
    • (2001) CMAJ , vol.164 , Issue.5 , pp. 620-621
    • Doyle, D.J.1    Vicente, K.J.2
  • 47
    • 0032071196 scopus 로고    scopus 로고
    • Applying human factors to the design of medical equipment: Patient-controlled analgesia
    • Lin L, Isla R, Doniz K, et al. Applying human factors to the design of medical equipment: patient-controlled analgesia. J Clin Monit Comput 1998; 14 (4): 253-63
    • (1998) J Clin Monit Comput , vol.14 , Issue.4 , pp. 253-263
    • Lin, L.1    Isla, R.2    Doniz, K.3
  • 48
    • 0023265299 scopus 로고
    • Mishaps with patient-controlled analgesia
    • White PF. Mishaps with patient-controlled analgesia. Anesthesiology 1987; 66 (1): 81-3
    • (1987) Anesthesiology , vol.66 , Issue.1 , pp. 81-83
    • White, P.F.1
  • 49
    • 67649290411 scopus 로고    scopus 로고
    • Institute for Safe Medication Practices. Misprogram a PCA pump? It's easy! [online]. Available from URL: www.ismp. org/Newsletters/acutecare/ articles/20040729-2.asp [Accessed 2008 May 15] 51. Joint Commission on Accreditation of Healthcare Organizations. Patient controlled analgesia by proxy [online]. Available from URL: http://www.jointcommission.org/ SentinelEvents/SentinelEventAlert/sea-33.htm [Accessed 2008 May 15]
    • Institute for Safe Medication Practices. Misprogram a PCA pump? It's easy! [online]. Available from URL: www.ismp. org/Newsletters/acutecare/ articles/20040729-2.asp [Accessed 2008 May 15] 51. Joint Commission on Accreditation of Healthcare Organizations. Patient controlled analgesia by proxy [online]. Available from URL: http://www.jointcommission.org/ SentinelEvents/SentinelEventAlert/sea-33.htm [Accessed 2008 May 15]
  • 50
    • 0004001942 scopus 로고    scopus 로고
    • online, Available from URL:, Accessed 2008 May 15
    • National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP taxonomy of medication errors [online]. Available from URL: http://www. nccmerp.org/medErrorTaxonomy.html [Accessed 2008 May 15]
    • NCC MERP taxonomy of medication errors
  • 51
    • 1542569628 scopus 로고    scopus 로고
    • Programming errors from patient-controlled analgesia
    • Doyle DJ. Programming errors from patient-controlled analgesia. Can J Anaesth 2003; 50 (8): 855-6
    • (2003) Can J Anaesth , vol.50 , Issue.8 , pp. 855-856
    • Doyle, D.J.1
  • 52
    • 31344470111 scopus 로고    scopus 로고
    • Medication errors and adverse drug events in an intensive care unit: Direct observation approach for detection
    • Kopp BJ, Erstad BL, Allen ME, et al. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med 2006; 34 (2): 415-25
    • (2006) Crit Care Med , vol.34 , Issue.2 , pp. 415-425
    • Kopp, B.J.1    Erstad, B.L.2    Allen, M.E.3
  • 53
    • 23844432611 scopus 로고    scopus 로고
    • The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care
    • Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005; 33 (8): 1694-700
    • (2005) Crit Care Med , vol.33 , Issue.8 , pp. 1694-1700
    • Rothschild, J.M.1    Landrigan, C.P.2    Cronin, J.W.3
  • 55
    • 0028978123 scopus 로고
    • Systems analysis of adverse drug events. ADE Prevention Study Group
    • Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 1995; 274 (1): 35-43
    • (1995) JAMA , vol.274 , Issue.1 , pp. 35-43
    • Leape, L.L.1    Bates, D.W.2    Cullen, D.J.3
  • 56
    • 0028012607 scopus 로고
    • Accuracy of technicians and pharmacists in identifying dispensing errors
    • Ness JE, Sullivan SD, Stergachis A. Accuracy of technicians and pharmacists in identifying dispensing errors. Am J Hosp Pharm 1994; 51 (3): 354-7
    • (1994) Am J Hosp Pharm , vol.51 , Issue.3 , pp. 354-357
    • Ness, J.E.1    Sullivan, S.D.2    Stergachis, A.3
  • 57
    • 1642369094 scopus 로고    scopus 로고
    • Occurrence of dispensing errors and efforts to reduce medication errors at the Central Arkansas Veteran's Healthcare System
    • Rolland P. Occurrence of dispensing errors and efforts to reduce medication errors at the Central Arkansas Veteran's Healthcare System. Drug Saf 2004; 27 (4): 271-82
    • (2004) Drug Saf , vol.27 , Issue.4 , pp. 271-282
    • Rolland, P.1
  • 58
    • 0025835383 scopus 로고
    • Checking of unit dose cassettes by pharmacy technicians at three Minnesota hospitals
    • Woller TW, Stuart J, Vrabel R, et al. Checking of unit dose cassettes by pharmacy technicians at three Minnesota hospitals. Am J Hosp Pharm 1991; 48 (9): 1952-6
    • (1991) Am J Hosp Pharm , vol.48 , Issue.9 , pp. 1952-1956
    • Woller, T.W.1    Stuart, J.2    Vrabel, R.3
  • 59
    • 0027321778 scopus 로고
    • A problem with a PCA pump [letter]
    • Youngs PJ. A problem with a PCA pump [letter]. Anaesthesia 1993; 48 (9): 829
    • (1993) Anaesthesia , vol.48 , Issue.9 , pp. 829
    • Youngs, P.J.1
  • 60
    • 0027515110 scopus 로고
    • A problem with the Graseby 3300 PCA pump
    • White E. A problem with the Graseby 3300 PCA pump. Anaesthesia 1993; 48 (11): 1013-4
    • (1993) Anaesthesia , vol.48 , Issue.11 , pp. 1013-1014
    • White, E.1
  • 61
    • 0035567897 scopus 로고    scopus 로고
    • Patient safety, potential adverse drug events, and medical device design: A human factors engineering approach
    • 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 (4): 274-84
    • (2001) J Biomed Inform , vol.34 , Issue.4 , pp. 274-284
    • Lin, L.1    Vicente, K.J.2    Doyle, D.J.3
  • 62
    • 0027378862 scopus 로고
    • Safety assessment of postoperative pain management by an acute pain service
    • Schug SA, Torrie JJ. Safety assessment of postoperative pain management by an acute pain service. Pain 1993; 55 (3): 387-91
    • (1993) Pain , vol.55 , Issue.3 , pp. 387-391
    • Schug, S.A.1    Torrie, J.J.2
  • 63
    • 0025070308 scopus 로고
    • Spouse-controlled analgesia [letter]
    • Wakerlin G, Larson Jr CP. Spouse-controlled analgesia [letter]. Anesth Analg 1990; 70 (1): 119
    • (1990) Anesth Analg , vol.70 , Issue.1 , pp. 119
    • Wakerlin, G.1    Larson Jr, C.P.2
  • 64
    • 0026557176 scopus 로고
    • Oversedation with patient controlled analgesia
    • Johnson T, Daugherty M. Oversedation with patient controlled analgesia. Anaesthesia 1992; 47 (1): 81-2
    • (1992) Anaesthesia , vol.47 , Issue.1 , pp. 81-82
    • Johnson, T.1    Daugherty, M.2
  • 65
    • 22144444586 scopus 로고    scopus 로고
    • Variability in intravenous medication practices: Implications for medication safety
    • Bates DW, Vanderveen T, Seger D, et al. Variability in intravenous medication practices: implications for medication safety. Jt Comm J Qual Patient Saf 2005; 31 (4): 203-10
    • (2005) Jt Comm J Qual Patient Saf , vol.31 , Issue.4 , pp. 203-210
    • Bates, D.W.1    Vanderveen, T.2    Seger, D.3
  • 66
    • 0031849629 scopus 로고    scopus 로고
    • A dangerous fault with a PCA pump [letter]
    • Christie L, Cranfield KA. A dangerous fault with a PCA pump [letter]. Anaesthesia 1998; 53 (8): 827
    • (1998) Anaesthesia , vol.53 , Issue.8 , pp. 827
    • Christie, L.1    Cranfield, K.A.2
  • 67
    • 0025270281 scopus 로고
    • Introducing patient-controlled analgesia for postoperative pain control into a district general hospital
    • Notcutt WG, Morgan RJ. Introducing patient-controlled analgesia for postoperative pain control into a district general hospital. Anaesthesia 1990; 45 (5): 401-6
    • (1990) Anaesthesia , vol.45 , Issue.5 , pp. 401-406
    • Notcutt, W.G.1    Morgan, R.J.2
  • 68
    • 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 (1): 95-7
    • (1992) Br J Anaesth , vol.69 , Issue.1 , pp. 95-97
    • Notcutt, W.G.1    Knowles, P.2    Kaldas, R.3
  • 69
    • 0023803994 scopus 로고
    • Patient-controlled analgesia: The need for caution. A case report and review of adverse incidents
    • Thomas DW, Owen H. Patient-controlled analgesia: the need for caution. A case report and review of adverse incidents. Anaesthesia 1988; 43 (9): 770-2
    • (1988) Anaesthesia , vol.43 , Issue.9 , pp. 770-772
    • Thomas, D.W.1    Owen, H.2
  • 70
    • 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 (5): 940
    • (2001) Anesthesiology , vol.94 , Issue.5 , pp. 940
    • Doyle, D.J.1    Vicente, K.J.2
  • 71
    • 0031989194 scopus 로고    scopus 로고
    • Unintentional bolus with Graseby 9300 pump [letter]
    • Chan S, Chen PP, Chui PT, et al. Unintentional bolus with Graseby 9300 pump [letter]. Anaesth Intensive Care 1998; 26 (1): 117
    • (1998) Anaesth Intensive Care , vol.26 , Issue.1 , pp. 117
    • Chan, S.1    Chen, P.P.2    Chui, P.T.3
  • 72
    • 0029076144 scopus 로고
    • Intravenous dead space and patient safety in patient-controlled analgesia [letter]
    • Doyle DJ, Nebbia SP. Intravenous dead space and patient safety in patient-controlled analgesia [letter]. Can J Anaesth 1995; 42 (7): 658
    • (1995) Can J Anaesth , vol.42 , Issue.7 , pp. 658
    • Doyle, D.J.1    Nebbia, S.P.2
  • 73
    • 0023941410 scopus 로고
    • Patient-controlled analgesia [letter]
    • Grey TC, Sweeney ES. Patient-controlled analgesia [letter]. JAMA 1988; 259 (15): 2240
    • (1988) JAMA , vol.259 , Issue.15 , pp. 2240
    • Grey, T.C.1    Sweeney, E.S.2
  • 74
    • 17644434831 scopus 로고    scopus 로고
    • Failure of a patient-controlled analgesia pump in a hyperbaric environment
    • Sanchez-Guijo JJ, Benavente MA, Crespo A. Failure of a patient-controlled analgesia pump in a hyperbaric environment. Anesthesiology 1999; 91 (5): 1540-2
    • (1999) Anesthesiology , vol.91 , Issue.5 , pp. 1540-1542
    • Sanchez-Guijo, J.J.1    Benavente, M.A.2    Crespo, A.3
  • 76
    • 67649247385 scopus 로고    scopus 로고
    • online, Available fromURL:, Accessed 2008May
    • Food and Drug Administration, Center for Devices and Radiological Health. Search MAUDE database [online]. Available fromURL: http://www.accessdata.fda. gov/scripts/ cdrh/cfdocs/cfMAUDE/search.cfm [Accessed 2008May 15]
    • Search MAUDE database , pp. 15
  • 77
    • 34447556985 scopus 로고    scopus 로고
    • Adverse events involving intravenous patient-controlled analgesia
    • Hankin CS, Schein J, Clark JA, et al. Adverse events involving intravenous patient-controlled analgesia. Am JHealth Syst Pharm 2007; 64 (14): 1492-9
    • (2007) Am JHealth Syst Pharm , vol.64 , Issue.14 , pp. 1492-1499
    • Hankin, C.S.1    Schein, J.2    Clark, J.A.3
  • 78
    • 67649293263 scopus 로고    scopus 로고
    • MEDMARX patient safety solutions
    • online, Available fromURL:, Accessed 2008 May 15
    • US Pharmacopeia. MEDMARX patient safety solutions. The National Database for Medication Errors [online]. Available fromURL: https://www.medmarx.com/ [Accessed 2008 May 15]
    • The National Database for Medication Errors
    • Pharmacopeia, U.S.1
  • 79
    • 67649290410 scopus 로고    scopus 로고
    • Santell JP, Cousins DD, Hicks R. Errors involving PCA pumps. Drug Topics 2004; Health-System Edition: 28-9
    • Santell JP, Cousins DD, Hicks R. Errors involving PCA pumps. Drug Topics 2004; Health-System Edition: 28-9
  • 80
    • 40349084050 scopus 로고    scopus 로고
    • Medication errors involving patient-controlled analgesia
    • Hicks RW, Sikirica V, Nelson W, et al. Medication errors involving patient-controlled analgesia. Am J Health Syst Pharm 2008; 65 (5): 429-40
    • (2008) Am J Health Syst Pharm , vol.65 , Issue.5 , pp. 429-440
    • Hicks, R.W.1    Sikirica, V.2    Nelson, W.3
  • 82
    • 14944351088 scopus 로고    scopus 로고
    • A controlled trial of smart infusion pumps to improve medication safety in critically ill patients
    • Rothschild JM, Keohane CA, Cook EF, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med 2005; 33 (3): 533-40
    • (2005) Crit Care Med , vol.33 , Issue.3 , pp. 533-540
    • Rothschild, J.M.1    Keohane, C.A.2    Cook, E.F.3
  • 83
    • 33748562195 scopus 로고    scopus 로고
    • Using failure mode and effects analysis to plan implementation of smart i.v. pump technology
    • Wetterneck TB, Skibinski KA, Roberts TL, et al. Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. AmJHealth Syst Pharm 2006; 63 (16): 1528-38
    • (2006) AmJHealth Syst Pharm , vol.63 , Issue.16 , pp. 1528-1538
    • Wetterneck, T.B.1    Skibinski, K.A.2    Roberts, T.L.3
  • 85
    • 0037495031 scopus 로고    scopus 로고
    • Improving safety with information technology
    • Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003; 348 (25): 2526-34
    • (2003) N Engl J Med , vol.348 , Issue.25 , pp. 2526-2534
    • Bates, D.W.1    Gawande, A.A.2
  • 86
    • 0026783418 scopus 로고
    • Computer-assisted drug data collection
    • Beers MH, Avorn J, Soumerai S, et al. Computer-assisted drug data collection. J Med Syst 1992; 16 (1): 1-6
    • (1992) J Med Syst , vol.16 , Issue.1 , pp. 1-6
    • Beers, M.H.1    Avorn, J.2    Soumerai, S.3
  • 87
    • 0037663736 scopus 로고    scopus 로고
    • Effects of computerized physician order entry and clinical decision support systems on medication safety: A systematic review
    • Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med 2003; 163 (12): 1409-16
    • (2003) Arch Intern Med , vol.163 , Issue.12 , pp. 1409-1416
    • Kaushal, R.1    Shojania, K.G.2    Bates, D.W.3
  • 88
    • 0035490930 scopus 로고    scopus 로고
    • Patient safety and computerized medication ordering at Brigham and Women's Hospital
    • Kuperman GJ, Teich JM, Gandhi TK, et al. Patient safety and computerized medication ordering at Brigham and Women's Hospital. Jt Comm J Qual Improv 2001; 27 (10): 509-21
    • (2001) Jt Comm J Qual Improv , vol.27 , Issue.10 , pp. 509-521
    • Kuperman, G.J.1    Teich, J.M.2    Gandhi, T.K.3
  • 89
    • 0038482036 scopus 로고    scopus 로고
    • Computer physician order entry: Benefits, costs, and issues
    • Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med 2003; 139 (1): 31-9
    • (2003) Ann Intern Med , vol.139 , Issue.1 , pp. 31-39
    • Kuperman, G.J.1    Gibson, R.F.2
  • 90
    • 33749186615 scopus 로고    scopus 로고
    • Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy
    • Poon EG, Cina JL, Churchill W, et al. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. Ann Intern Med 2006; 145 (6): 426-34
    • (2006) Ann Intern Med , vol.145 , Issue.6 , pp. 426-434
    • Poon, E.G.1    Cina, J.L.2    Churchill, W.3
  • 91
    • 3042747537 scopus 로고    scopus 로고
    • Information technology and patient safety in nursing practice: An international perspective
    • Van de Castle B, Kim J, Pedreira ML, et al. Information technology and patient safety in nursing practice: an international perspective. Int J Med Inform 2004; 73 (7-8): 607-14
    • (2004) Int J Med Inform , vol.73 , Issue.7-8 , pp. 607-614
    • Van de Castle, B.1    Kim, J.2    Pedreira, M.L.3
  • 92
    • 0141794323 scopus 로고    scopus 로고
    • Effective drugallergy checking: Methodological and operational issues
    • Kuperman GJ, Gandhi TK, Bates DW. Effective drugallergy checking: methodological and operational issues. J Biomed Inform 2003; 36 (1-2): 70-9
    • (2003) J Biomed Inform , vol.36 , Issue.1-2 , pp. 70-79
    • Kuperman, G.J.1    Gandhi, T.K.2    Bates, D.W.3
  • 93
    • 7944229223 scopus 로고    scopus 로고
    • Prevention of prescription errors by computerized, on-line, individual patient related surveillance of drug order entry
    • Oliven A, Zalman D, Shilankov Y, et al. Prevention of prescription errors by computerized, on-line, individual patient related surveillance of drug order entry. Stud Health Technol Inform 2002; 90: 632-4
    • (2002) Stud Health Technol Inform , vol.90 , pp. 632-634
    • Oliven, A.1    Zalman, D.2    Shilankov, Y.3
  • 94
    • 33847361820 scopus 로고    scopus 로고
    • Using bar-code technology and medication bservation methodology for safer medication administration
    • Paoletti RD, Suess TM, Lesko MG, et al. Using bar-code technology and medication bservation methodology for safer medication administration. Am J Health Syst Pharm 2007; 64 (5): 536-43
    • (2007) Am J Health Syst Pharm , vol.64 , Issue.5 , pp. 536-543
    • Paoletti, R.D.1    Suess, T.M.2    Lesko, M.G.3


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.