Stein Susan J, Sarff Laura, Tyler Robin
Quality Improvement Program, Los Angeles County Department of Health Services, Los Angeles, USA.
Jt Comm J Qual Saf. 2004 Apr;30(4):224-9, 173. doi: 10.1016/s1549-3741(04)30025-0.
After two fatal cases of catheter overinsertion, a pilot study showed that a shorter catheter seemed to provide a safer alternative.