@misc{misca14b0597, title = {Analysis of a medication error occurring at a university hospital: root cause analysis}, author = {Teixeira, Thalyta Cardoso A. and Cassiani, Silvia Helena De Bortoli and Optiz, Simone Perufo and Telles Filho, Paulo Celso Prado}, year = {2005}, booktitle = {Internacional of Congress of Pharmaceutical Science (CIFARP} }