A system factors analysis of "line, tube, and drain" incidents in the intensive care unit.
Needham DM, Sinopoli DJ, Thompson DA, et al. A system factors analysis of "line, tube, and drain" incidents in the intensive care unit. Crit Care Med. 2005;33(8):1701-1707.
The authors reviewed anonymous adverse event reports from an intensive care unit and analyzed the systemic factors contributing to invasive line, tube, and drain incidents.