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L’errore nella somministrazione di terapia farmacologica endovenosa nelle Unità di Terapia Intensiva: stato dell’arte e strategie.

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Abstract

Introduction: several studies show that medication errors in the Intensive Care Unit (ICU) are potential, daily, life-threatening events for patients. This type of error occurs more frequently in the ICU due to features of the specific context such as: the complexity of patient’s condition, the large quantity of drugs administered intravenously, the complicated calculations often required to provide optimal doses, the frequent changes in prescriptions, the continuous updating of the infusion speed, the potential incompatibility between intravenous drugs, the need to manage large amounts of information in emergency situations. Aim: the aim of this review is to describe the connections between knowledge, behavior and the learning needs of intensive care nurses and the safety of intravenous medications, through error analysis in terms of: incidence, main types, associated drugs, situations, consequences, causes and risk reduction strategies. Materials and methods: review of the literature. The research was conducted on PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid-SP, Cochrane Library. The research was limited to articles written in English in the last 10 years. Result: from these studies, the importance of the nurses’ role, behaviors and knowledge in the prevention of medication errors emerges clearly. Conclusions: the knowledge of the nursing team should be periodically enhanced through specific training. This appears to be a valid strategy for maintaining a high level of medication safety in the Intensive Care Unit.

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... Scientific literature divides the factors that contribute to the occurrence of harmful or potentially harmful events into (i) factors related to the personal and professional characteristics, that are human factors, of the healthcare workers and (ii) factors related to the organization of the drug management process 13 . ...
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OBJECTIVE: Medication errors are one of the most common causes of negative events affecting patient safety all over the world. Scientific literature divides the factors that contribute to the occurrence of harmful events into factors related to the characteristics of the healthcare workers and factors related to the organization of the drug management process. The aim of the study was to examine the knowledge , attitudes and behaviours related to medication errors among Italian and Maltese nurses. SUBJECTS AND METHODS: Cross-sectional survey of nurses working in Intensive Care settings in Italian and Maltese hospitals was conducted. A valid and reliable questionnaire used in previous studies was adapted for online use. Despite improved reporting, The Strengthening the Reporting of Observational Studies in Epidemiology was used. RESULTS: Findings showed good psychomet-ric properties and reliability. MANOVA demonstrated significant differences in nurses' perception of the pharmacist presence during medication process and of the use of computerized provider order entry. MANOVA also demonstrated significant differences in the control of vital parameters and the application of the 8 right. CONCLUSIONS: These findings support the contention that knowledge, attitude and behaviour of nurses is similar across different contexts in different countries wherein nurse training is harmonised and regulated through a transnational directive.
... Several studies have shown that the risk of MEs in prescription is related to deficiency in management of dosage formulation and incomplete data (Bowdle, 2003;Grünewald & Mack, 2001;Krähenbühl-Melcher et al., 2007;Mack, Kuc, & Grünewald, 2000;Miasso et al., 2009). Errors in administration are more closely related to environmental and professional factors such as stress or work overload (Donati, Tartaglini, & Di Muzio, 2015;Elganzouri, Standish, & Androwich, 2009;Frith, 2013;Kendall-Gallagher & Blegen, 2009). ...
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Aim: To determine the prevalence and magnitude of medication errors and their association with patients' socio-demographic and clinical characteristics and nurses' work conditions. Design: An observational, analytical, cross-sectional and ambispective study was conducted in critically ill adult patients. Methods: Data concerning prescription errors were collected retrospectively from medical records and administration errors were identified through direct observation of nurses during drug administration. Those data were collected between April and July 2015. Results: A total of 650 prescription errors were identified for 961 drugs in 90 patients (mean error 7 [SD 4.1] per patient) and prevalence of 47.1% (95% CI 44-50). The most frequent error was omission of the prescribed medication. Intensive Care Unit stay was a risk factor associated with omission error (OR 2.14; 1.46-3.14: P <.01). A total of 294 administration errors were identified for 249 drugs in 52 patients (mean error 6 [SD 6.7] per patient) and prevalence of 73.5% (95% CI 68-79). The most frequent error was interruption during drug administration. Admission to the Intensive Care Unit (OR 0.37; 0.21-0.66: P <.01), nurses' morning shift (OR 2.15; 1.10-4.18: P=0.02) and workload perception (OR 3.64; 2.09-6.35: P <.01) were risk factors associated with interruption. Conclusions: Medication Errors in prescription and administration were frequent. Timely detection of Errors and promotion of a medication safety culture are necessary to reduce them and ensure the quality of care in critically ill patients. Impact: Medication errors occur frequently in the intensive care unit but are not always identified. Due to the vulnerability of seriously ill patients and the specialized care they require, an error can result in serious adverse events. The study shows that medication errors in prescription and administration are recurrent but preventable. These findings contribute to promote awareness in the proper use of medications and guarantee the quality of nursing care.
... Per quanto riguarda la realtà italiana esiste un solo studio che abbia indagato lo stato dell'arte in materia di errori di somministrazione della terapia endovenosa [14] , ma nessuno studio osservazionale che abbia descritto le concentrazioni dei farmaci di uso comune impiegate nelle Terapie Intensive italiane. ...
Article
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Purpose: To assess the frequency and contributing factors of medication and dislodgement errors attributable to common routine processes in a cohort of intensive care units, with a special focus on the potential impact of safety climate. Methods: A prospective, observational, 48 h cross sectional study in 57 intensive care units (ICUs) in Austria, Germany, and Switzerland, with self-reporting of medical errors by ICU staff and concurrent assessment of safety climate, workload and level of care. Results: For 795 observed patients, a total of 641 errors affecting 269 patients were reported. This corresponds to a rate of 49.8 errors per 100 patient days related to the administration of medication, loss of artificial airways, and unplanned dislodgement of lines, catheters and drains. In a multilevel model predicting error occurrence at the patient level, odds ratios (OR) per unit increase for the occurrence of at least one medical error were raised for a higher Nine Equivalents of Nursing Manpower Use Score (NEMS) (OR 1.04, 95 % CI 1.02-1.05, p < 0.01) and a higher number of tubes/lines/catheters/drains (OR 1.02, 95 % CI 1.01-1.03, p < 0.01) at the patient level and lowered by a better safety climate at the ICU level (OR per standard deviation 0.67, 95 % CI 0.51-0.89, p < 0.01). Conclusions: Safety climate apparently contributes to a reduction of medical errors that represent a particularly error-prone aspect of frontline staff performance during typical routine processes in intensive care.
Article
Objectives: This study explores nurses' use of bar code medication administration (BCMA) technology from a human factors viewpoint. The BCMA technology consists of a medication network server and handheld devices that connect to medication administration record data through wireless radiofrequency link. Methods: A total of 62 observations of medication administration were conducted in 1 academic hospital. Observations were performed by a team of 2 people (a human factors engineer and a pharmacist) in a variety of critical care and medical/surgical units. Data were recorded on the medication administration task, the BCMA technology, organizational factors (in particular interruptions), the physical environment, and various individual factors related to the nurses and patients. Results: Eighteen different sequences were identified and represented very large variability in the order in which steps of the medication administration process are performed; some of the sequences can be considered as potentially unsafe acts. We identified various working conditions that can hinder the medication administration process. For example, 20 instances of interruptions were observed. Some patient factors (e.g., isolation patients) were also identified that made the BCMA-based medication administration process challenging. Conclusions: When introducing a new technology into the health care environment, it is important to assess changes in workflow and tasks that may result from the use of the technology. Our study shows the use of direct observation in helping to identify the work system factors that facilitate or hinder the medication administration tasks. This information can help health care organizations identify opportunities to redesign the process and/or the technology to maximize worker efficiency, interaction with the technology, and patient safety.
Article
Objectives: To examine relationships among organizational context (characteristics of the external, hospital, and nursing unit environments), organizational structure (unit capacity, work engagement, and work conditions), patient characteristics (age, sex, and health status), safety climate, and effectiveness (medication errors and falls) in acute care hospitals. Methods: Data came from 278 medical-surgical units at 143 hospitals that participated in the Outcomes Research in Nursing Administration Project II, a longitudinal multisite study. Results: Selected measures of the external, hospital, and nursing unit environment had significant influences on the organizational structure of nursing units, which in turn significantly predicted unit-level safety climate. However, structural measures had limited effects on medication errors and falls. Patient age and health status were associated with falls but not with medication errors. There was a significant structure-safety climate interaction, where units with higher levels of unit capacity but lower levels of safety climate reported fewer medication errors. In contrast, units with higher levels of unit capacity and higher levels of safety climate reported more falls. Conclusions: There are important influences of contextual, structural, and safety climate factors on both medication errors and falls. The limited effect of structure on effectiveness and the differential moderating effect of safety climate suggest that future studies may benefit from the use of theoretical models that are targeted more specifically to the explanation of a particular type of adverse event.
Article
Background: Patient safety is considered an antecedent of quality of hospital care. The explicit need to focus on quality of care underpins the aim of the study to evaluate the safety culture and teamwork climate in the public intensive care units (ICUs) of the 5 regional public hospitals in Cyprus as measured by a validated safety attitudes tool. Methods: A questionnaire that included the Greek version of the generic version of the Safety Attitudes Questionnaire has been used in all public ICUs across Cyprus. Results: There were 132 (76.7%) fully completed questionnaires of 172 registered nurses who are currently positioned in Cyprus ICUs. The mean age of the participants was 33.09 ± 08.16 years. The mean of the total working years as a nurse was 10.82 ± 8.47 years, whereas the mean of the total work experience in the ICU units was 6.05 ± 5.16 years. The sample's age strongly correlated with teamwork, nurses with more years of experience rated higher teamwork (P = .02), and their perceptions of management were better than those of the inexperienced nurses. Conclusions: Considerable safety climate variations between the ICUs of the regional hospitals of Cyprus have been verified. Age, infrastructure, the severity of cases, and the nurse skill mix are variables that affect the patient safety culture in an ICU environment.
Article
The main aim of the present study was to evaluate interruptions that occurred during medication rounds within a hospital-based, multi-intervention programme. There are no standardized ways to reduce medication interruptions during medication rounds and no guidelines or standards on the use of tabards during medication rounds. In 2006, a preliminary baseline evaluation (T0) was conducted at the hospital level observing the occurrence of interruptions during medication rounds in daily practice. Subsequently, a hospital-based policy for a multi-intervention medication round programme was implemented at of the beginning of 2008 (T1). After 18 months, an evaluation of the frequency of interruptions was repeated (T2). At T0, 298 interruptions were observed for 945 medications administered, or one for every 3.2 medications given. At T2, 385 interruptions were observed for 895 medications given, an interruption for every 2.3 medications administered (P = 0.041). At T0, the mean interruption duration per medication round was 10.48 min whereas at T2 it was 5.08 min. Patient interruptions were reduced (26.5-14.0%, P = 0.05); in spite of this effect, staff member interruptions increased (15.8-40.5%, P = 0.01). With the implementation of the multi-intervention programme, the interruptions changed their pattern. While wearing the red tabard was paradoxically effective with patients, it was ineffective with other staff members. Before introducing new strategies, an evaluation of their appropriateness with regard to the culture of the patients and nurses is recommended: in the present study, patients seem to have considered the warning message worn by nurses as mainly intended for them.
Article
Aim: This study explores the effectiveness of an educational intervention on nurses' knowledge regarding the administration of high-alert medications. Background: Nurses' insufficient knowledge is considered to be one of the most significant factors contributing to medication errors. Most medication errors cause no harm to patients, but the incorrect administration of high-alert medications can result in serious consequences. A previous study by the same authors validated 20 true/false questions concerning high-alert medications and suggested that the topic be taught to nurses (Hsaio, et al., 2010. Nurses' knowledge of high-alert medications: Instrument development and validation. Journal of Advanced Nursing, 66(1), 177-199.). Methods: A randomized controlled trial was employed in 2009 in Taiwan. Twenty-one hospital wards and 232 nurses were randomized to control and intervention groups. The sixty-minute educational intervention was based on the viewing of a Powerpoint file developed for this study. The results were compared pre-intervention and six weeks post-intervention by means of a test comprising the 20 questions regarding high-alert medications. Findings: The pre-intervention baseline data for correct answer rate was 75.8% (mean; n=232). After the intervention, the post-test showed significant improvement in the intervention group (n=113) (pre vs. post; 77.2±15.5 vs. 94.7±7.6; paired t=10.82, p<0.0001) but not in the control group (n=112) (pre vs. post; 74.3±14.7 vs. 75.5±14.2; paired t=0.60; p=0.247). Conclusions: Educational intervention appears to be effective in strengthening nurses' knowledge of high-alert medications. The Powerpoint file presented teaching material which is both suitable and feasible for hospital-based continuing education.
Article
Nursing workload is increasingly thought to contribute to both nurses' quality of working life and quality/safety of care. Prior studies lack a coherent model for conceptualising and measuring the effects of workload in healthcare. In contrast, we conceptualised a human factors model for workload specifying workload at three distinct levels of analysis and having multiple nurse and patient outcomes. To test this model, we analysed results from a cross-sectional survey of a volunteer sample of nurses in six units of two academic tertiary care paediatric hospitals. Workload measures were generally correlated with outcomes of interest. A multivariate structural model revealed that: the unit-level measure of staffing adequacy was significantly related to job dissatisfaction (path loading=0.31) and burnout (path loading=0.45); the task-level measure of mental workload related to interruptions, divided attention, and being rushed was associated with burnout (path loading=0.25) and medication error likelihood (path loading=1.04). Job-level workload was not uniquely and significantly associated with any outcomes. The human factors engineering model of nursing workload was supported by data from two paediatric hospitals. The findings provided a novel insight into specific ways that different types of workload could affect nurse and patient outcomes. These findings suggest further research and yield a number of human factors design suggestions.
Article
Medication errors (MEs) and adverse drug events (ADEs) are both common and under-reported in the intensive care setting. The definitions of these terms vary substantially in the literature. Many methods have been used to estimate their incidence. A systematic review was done to assess methods used for tracking unintended drug events in intensive care units (ICUs). Studies published up to 22 June 2007 were identified by searching eight online databases, including Medline. In total, 613 studies were evaluated for inclusion by two reviewers. The authors selected 29 papers to analyse; all studies took place in an ICU, were reproducible and reported ICU-specific rates of events. Rates of MEs varied from 8.1 to 2344 per 1000 patient-days, and ADEs from 5.1 to 87.5 per 1000 patient-days. The definitions of ADE and ME in the studies varied widely. Much variation exists in reported rates and definitions of ADEs and MEs in ICUs. Some of this variation may be due to a lack of standard definitions for ADEs and MEs, and methods for detecting them. Further standardisation is needed before these methods can be used to evaluate process improvements.
Article
This study examined nurses' reasons for medication errors, reasons for not reporting errors, and perceived unit-reporting practices. It compared nurses' anonymous reports of medication errors with those from institutional reporting mechanisms. Qualities of the work environment, staffing, and workload were evaluated to determine associations with perceived error-reporting practices. The study findings have immediate applicability as a baseline for system improvements.
Article
The purpose of the study was to examine the frequency and perceived risk of interruptions to nurses during drug rounds in seven Italian surgical wards. Management of drug therapy is an integral part of the clinical role of nurses. Many errors are caused by interruptions to which the nurse is subjected during the drug rounds. However, the frequency of interruptions to nurses during drug rounds has not yet been documented. An observational study design was developed: (1) 56 randomized drug rounds, eight for each ward included, were observed and (2) 28 convenience samples of observed nurses were interviewed. The administration of a total of 945 medications was observed, an average of 2.2 per patient being treated: 298 interruptions were observed (one for every 3.2 drugs given). Ten different categories of interruption emerged. The highest risk of error as a result of interruption perceived by these nurses was related to the management of telephone calls. Many of the interruptions as a result of the organization of work could be avoided: one organizational priority should be to create a calm atmosphere for administering drugs. Ways to develop a calm atmosphere are discussed.
Article
This paper is a report of a study to investigating the incidence types and causes of medication errors (MEs) and the consequences for patients. Background. Medication errors are a common problem in hospitals around the world, including those in Brazil. An exploratory, quantitative survey design was used and 44 adult inpatients were studied over a 30-day period in 2006. Three different methods were employed: anonymous self-reports, staff interviews and review of patient prescriptions. A total of 305 MEs was observed. The mean (sd) number was 6.9 (6.8) per patient. The numbers of MEs per day differed statistically significantly between the two groups with length of stay in the intensive care unit of <1 week and more than 1 week, respectively, with mean (sd) of 0.4 (0.38) vs. 0.73 (0.39) The most frequent types were: omission (71.1%), wrong time of administration (11.5%), and prescribing errors (4.6%). The main causes were: medication not available in the hospital (41%); pharmacy stocking and delivery problems (16.3%); transcription errors (11%). No death was directly related to any ME. There is a need to develop a culture of safety and quality in patient care. An understanding of the profile of ME types and frequencies in an institution is fundamental to raise awareness and implement measures to avoid them. Structural and procedural changes in hospital organization, with a focus on the efficacy, efficiency, and effectiveness of the medication system are needed to reduce MEs.
Article
To compare the frequency and preventability of adverse drug events and potential adverse drug events in intensive care units (ICUs) and non-ICUs. To evaluate systems factors involving the individual caregivers, care unit teams, and patients involved in each adverse drug event by comparing ICUs with non-ICUs and medical ICUs with surgical ICUs. Prospective cohort study. Participants included all 4,031 adult admissions to a stratified, random sample of 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Units included two medical and three surgical ICUs and four medical and two surgical general care units. Two tertiary care hospitals: Eleven medical and surgical units, including two medical and three surgical ICUs. Adult admissions (n = 4,031). None. Rate of preventable adverse drug events and potential adverse drug events, length of stay, charges, costs, and measures of the unit's environment. Incidents were detected by stimulated self-report by nurses and pharmacists and by daily review of all charts by nurse investigators. Incidents were subsequently classified by two independent reviewers as to whether they represented adverse drug events or potential adverse drug events and as to severity and preventability. Those individuals involved in the preventable adverse drug event and potential adverse drug event underwent detailed interviews by peer case-investigators. The rate of preventable adverse drug events and potential adverse drug events in ICUs was 19 events per 1000 patient days, nearly twice that rate of non-ICUs (p <.01). The medical ICU rate (25 events per 1000 patient days) was significantly (p <.05) higher than the surgical ICU rate (14 events per 1000 patient days). When adjusted for the number of drugs used in the previous 24 hrs or ordered since admission, there were no differences in rates between ICUs and non-ICUs. ICU acuity, length of stay, and severity of the adverse drug event were greater in ICUs than non-ICUs, but there were no differences between medical ICU and surgical ICU patients. Structured interviews indicated almost no differences between ICUs and non-ICUs for many characteristics of the patient, patient care team, systems, and individual caregivers. The rate of preventable and potential adverse drug events was twice as high in ICUs compared with non-ICUs. However, when adjusted for the number of drugs ordered, there was no greater likelihood for preventable adverse drug events and potential adverse drug events to occur in ICUs than in non-ICUs. Preventable adverse drug events and potential adverse drug events occurred in units that functioned normally and involved caregivers who were working under reasonably normal circumstances, not at the extremes of workload, stress, or a difficult environment.
Article
The validity and cost-effectiveness of three methods for detecting medication errors were examined. A stratified random sample of 36 hospitals and skilled-nursing facilities in Colorado and Georgia was selected. Medication administration errors were detected by registered nurses (R.N.s), licensed practical nurses (L.P.N.s), and pharmacy technicians from these facilities using three methods: incident report review, chart review, and direct observation. Each dose evaluated was compared with the prescriber's order. Deviations were considered errors. Efficiency was measured by the time spent evaluating each dose. A pharmacist performed an independent determination of errors to assess the accuracy of each data collector. Clinical significance was judged by a panel of physicians. Observers detected 300 of 457 pharmacist-confirmed errors made on 2556 doses (11.7% error rate) compared with 17 errors detected by chart reviewers (0.7% error rate), and 1 error detected by incident report review (0.04% error rate). All errors detected involved the same 2556 doses. All chart reviewers and 7 of 10 observers achieved at least good comparability with the pharmacist's results. The mean cost of error detection per dose was $4.82 for direct observation and $0.63 for chart review. The technician was the least expensive observer at $2.87 per dose evaluated. R.N.s were the least expensive chart reviewers at $0.50 per dose. Of 457 errors, 35 (8%) were deemed potentially clinically significant; 71% of these were detected by direct observation. Direct observation was more efficient and accurate than reviewing charts and incident reports in detecting medication errors. Pharmacy technicians were more efficient and accurate than R.N.s and L.P.N.s in collecting data about medication errors.
Article
Discussions between the children's services manager at an National Health Service trust, and a children's nursing lecturer from the trust's partnering university clarified that there was a need to establish a greater understanding of the local circumstances surrounding adverse events in drug administration – particularly when those events involved nurses. Indeed it is claimed that nurses spend up to 40% of their time administering drugs. It was agreed that a collaborative research study, specifically designed to explore the nature of drug administration errors, could inform future trust policies and procedures around both drug administration and error, as well as the various university curricula concerning drug administration. This study, supported by senior management in the trust, and the chair of the local research ethics committee, has commenced. The first part of this study – an introductory literature review, is presented here. The work of O'Shea [J Clin Nurs (1999)8:496–504] is significant in structuring the review that bears a number of recurring themes. It is not the intention of this literature review to reappraise O'Shea's original critique but to expand on her work, offer a contemporaneous perspective in the light of studies and reports published since 1999, and reset the topic in the context of clinical governance. This literature review has already provided an underpinning framework for a pilot questionnaire to staff who have been involved in drug administration errors and is also the basis for curricular input to preregistration students on the subject of risk management and drug administration. In conclusion, several recommendations about the shape of future research are offered.
Safety initiatives have primarily focused on physicians despite the fact that nurses provide the majority of direct inpatient care. Patient surveillance and preventing errors from harming patients represent essential nursing responsibilities but have received relatively little study. The study was conducted between July 2003 and July 2004 in a 10-bed academic coronary care unit. Direct observation of nursing care and solicited and institutional incident reports were used to find potential incidents. Two physician reviewers rated incidents as to the presence, preventability, and potential severity of harm of errors and associated factors. Overall data were collected for 147 days, including 150 hours of direct observation. One hundred forty-two recovered medical errors were found, including 61% (86/142) during direct observations. Most errors (69%; 98/142) were intercepted before reaching the patients. Errors that reached patients included 13% that were mitigated before resulting in harm and 18% that were ameliorated before more severe harm could occur. Protecting patients from the potentially dangerous consequences of medical errors is one of the many ways critical care nurses improve patient safety. Interventions designed to increase the ability of nurses to recover and promptly report errors have the potential to improve patient outcomes.
Article
To determine the frequency of medication errors that occurred during the preparation and administration of IV drugs in an intensive care unit. The study was conducted in a 12-bed intensive care unit of one of the largest teaching hospitals in Tehran. Data were collected over 16 randomly selected days at different medication round times, between July and September 2006. A trained observer accompanied nurses during intravenous (IV) drug rounds. Medication errors were recorded during the observation times of IV drug administration and preparation. Drugs with the highest rate of use in the intensive care unit (ICU) were selected. Details of the process of preparation and administration of the selected drugs were compared to an informed checklist which was prepared using reference books and manufacturers' instructions. We observed a total of 524 preparations and administrations. The calculated number of opportunities for error was 4040. The number of errors identified were 380/4040 (9.4%). Of those, 33.6% were related to the preparation process and 66.4% to the administration process. The most common type of error (43.4%) was the injection of bolus doses faster than the recommended rate. Amikacin was involved in the highest rate of error (11%) among all the selected medications. It was found that the IV rounds conducted at 9:a.m. had the highest rate of error (19.8%). No significant correlation was found between the rate of error and the nurses' age, sex, qualification, work experience, marital status, and type of working contract (permanent or temporary). Since our system is devoid of a well-organized reporting system, errors are not detected and consequently not prevented. Administrators need to take the initiative of developing systems that guarantee safe medication administration.
Preventing pediatric medication errors
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Drug-related problems in hospitals: a review of the recent literature
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Incidence of adverse drug events and medication errors in intensive care units: a prospective multicenter study
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Association of psychological and physiological measures of stress in health-care professionals during an 8-week mindfulness meditation program: mindfulness in practice
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