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[\'Emily G. Messing is a clinical pharmacy manager, informatics, Renu S. Abraham is a patient safety manager, Nicholas J. Quinn is a clinical pharmacy manager, critical care, and Elizabeth A. Duthie is director of patient safety, all at Montefiore Medical Center, Bronx, NY. The authors acknowledge Christina Rohan for her photography assistance and Theresa Madaline, Mary Ellen Lindros, Mark Sinnett, Inessa Gendlina, and Maureen Scanlan for their feedback on the manuscript prior to submission. Contact author: Emily G. Messing, emessing@montefiore.org. The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.\']
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