Transcript Patient Safety

Patient Safety
Evelyn M. Hickson, RN, MSN, CNS, WCC
Objectives
By the end of the presentation, the participant will be
able to:
1.
Describe the most common causes of medication errors
and the actions needed to ensure safe medication
administration
2.
Be able to state 4 current national patient safety goals
3.
Describe the principle of professional, accountable
communication
4.
Identify perinatal risk management strategies
Patient Safety
1. Are we as nurses responsible for
ensuring patient safety?
2. Do nurses have a medical-legal
responsibility to provide safe patient
care?
3. What methods do nurses have to use to
facilitate the provision of safe patient
care?
Definition
 Patient safety is a discipline in the health care
sector that applies safety science methods
toward the goal of achieving a trustworthy
system of health care delivery. Patient safety
is also an attribute of health care systems; it
minimizes the incidence and impact of, and
maximizes recovery from, adverse events.
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What Exactly Is Patient Safety?
Linda Emanuel, MD, PhD, Don Berwick, MD, MPP, James Conway, MS, John Combes, MD, Martin Hatlie, JD, Lucian
Leape, MD, James Reason, PhD, Paul Schyve, MD, Charles Vincent, MPhil, PhD, and Merrilyn Walton, PhD.*, Advances in
Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): Agency for Healthcare
Research and Quality; 2008 Aug.
2013 Hospital National Patient
Safety Goals
 Joint Commission of Accredited Health Care
Organizations (JCAHO or “Joint”)
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Changes have been made and since the
mandated implementation of NPSG from the
Joint in 2004
Not all of the current safety goals apply to the
in-patient acute care setting
Hospital has 15 for 2013 – No new ones were
added for this year
www.jointcommision.org
Identify Patients Correctly
1. NPSG.01.01.01 - Use at least two (2)
patient identifiers whenever:
Giving medications
 Providing Care
 Giving any Treatments
 Providing Services
2. NPSG.01.03.01 –Make sure that the correct
patient gets the correct blood when they get a blood
transfusion
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Improve the effectiveness of
communication among caregivers
3. NPSG.02.03.01
 Standardize a list of abbreviations, acronyms,
symbols, and dose designations that are not
be used throughout the organization
hs = hour of sleep
bid = twice per day
MgSO4 = magnesium sulfate
Improve the effectiveness of
communication among caregivers
 For verbal or telephone orders or telephone
reporting of critical test results, verify the
complete order or test result by having the
person receiving the information record and
“read-back” the complete order or test result
Improve the effectiveness of
communication among caregivers
 Measure, assess and, if appropriate, take
action to improve the timeliness of reporting,
and the timeliness of receipt by the
responsible licensed caregiver, of critical test
results and values.
Improve the effectiveness of
communication among caregivers
 Implement a standardized approach to “handoff” communications, including an
opportunity to ask and respond to questions.
 Clear, concise, factual, appropriate report
when patient is transferring within facility, to
different level of care or to another facility
 Team approach to conflict
Professional Communication
 Multiple studies and publications by JCAHO found
that health care worker’s inability to communicate
effectively contribute to errors and problems within
health care that are typically avoidable.
Medication errors
Patient safety
Quality of care
Nursing staffing and turnover
Joint Commission Publications
http://www.jointcommission.org/Advancing_Effective_
Communication/
SBAR
 Situation-what is going on with the patient
at this time
 Background-significant medical and
obstetrical history
 Assessment-vital signs, labs, fetal
monitoring assessment
 Recommendation-what you want from the
MD/provider – order(s), actions,etc.
SBAR
 Documentation
 Patient Hand-off – Report
 Conversations with MD/Providers
Perinatal SBAR
30-60 Second
Report
SBAR Report
Situation
Background
Assessment
Recommendation
Before Calling the Provider:
1. Assess the patient
2. Read the most current notes, lab data, orders, etc
3. Have the chart in hand
Obstetric Patient
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Identify yourself and where you are calling from
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Give patient name and reason for call:
“Pt was admitted for___________ and/or has recently had a _____________”
“I am concerned about____________”
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FHR pattern
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Labor Progress
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Contract Pattern (hyperstim or lack of)
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BP/Vital signs
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Vag Bleeding, etc
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G___ P___ @ _______wks gest
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OB Attending ______________
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Significant med history _____________
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Significant OB history __________
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Problems with current pregnancy _______
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Patient complaints are____________
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Patient pain level _____________
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Maternal vital signs
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Cervical exam
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Labor progress
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FHR – Variab, Baseline, Accel, Decels, UC pattern, reassure Vs non-reassuring
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Lab values that are abnormal or changed
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Interventions you have had to implement and the patient’s response
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Your conclusions about the present situation
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What I would like from you is _________________ (I need you to come now to assess the patient,
etc…)
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Be specific about the time frame
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Be specific about interventions (FSE, IUPC, Pit, Terb)
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Clarify orders, vital signs, labor plans, when to call back, lab work, etc…
Other Methods
 Key phrases that stop every member of the
team:
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Huddle
“Can I have a moment”
“Team Up”
Rounds
Seven Areas Where
Communication Breaks Down
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Broken rules – not following policy/protocols
Mistakes
Lack of support – from team, peers, administration
Incompetence
Poor teamwork
Disrespect
Micromanagement
Actions
What
actions can
we as
nurses take
in order to
attend to
these 7
essential
areas?
Broken Rules
 Shortcuts can be dangerous when it comes to
patient care
 Policies and procedures are considered
institutional standards / guidelines
Mistakes
 Important to follow directions
 Ability to make sound clinical judgments that are
appropriate and individualized for the patient
 Critical Thinking Skills
 Assessment skills
 Triaging and diagnosing
 Requesting treatment and assistance
Lack of Support
 Willingness to help, mentor, precept, answer
questions, be a resource
 Be an active team player – help out
 Give emotional support
 Pats on the back for a job well-done
Incompetence
 Precept
 Mentor
 Educate
 Report – at times first line of action, other
times last. Patient safety comes first.
Poor Teamwork
 Don’t participate in gossip
 Participate and lead team building activities
 Celebrate the things to be grateful for – the
positives
 Promotion of a culture that is focused on the
patient – improved safety and quality of care
Disrespect
 Do not promote or participate in:
 Insulting others
 Being condescending
 Rude behavior
 Insolent behavior
 Insubordination to supervisors
 Portraying yourself and your profession negatively
to the public, students, patients, families and peers
Micromanagement
 Do not participate in or allow others to:
Abuse authority
Pull rank
Bully
Threaten
Force a point of view just to be right
Perspective
“No one can make you feel inferior
without your consent”
Eleanor Roosevelt
Improve the safety of using
medications
4. NPSG.03.04.01 - Label all medications,
medication containers (syringes, medicine
cups, basins), or other solutions on and off the
sterile field and in the areas where supplies are
set up.
Improve the safety of using
medications
 Identify and, at a minimum, annually review
a list of look-alike/sound-alike drugs used by
the organization, and take action to prevent
errors involving the interchange of these
drugs.
 Standardize and limit the number of drug
concentrations used by the organization
Improve the safety of using
medications
 5. NPSG.03.05.01 – Take extra care with
patients taking medications to thin their
blood
Accurately and completely
reconcile medications across the
continuum of care
6. NPSG.03.06.01
 Record and pass along correct information
about the patient’s medications
 Compare any new medications
ordered/started during hospital stay with
previously used medications
 Make sure the patient knows how to take
them – including food and drug interactions
Improve the Safety of HighAlert Medications
Complete lists available on www.ismp.org
 Anti-arrhythmics
 Anti-coagulants
 Chemotherapy
 Vasopressors
 Insulin
 Sedation and Opiates
 PCA/Epidural Medications
 Concentrated electrolytes
Other Medication Safety
Recommendations
 Pumps with alarm systems
 Distribution Units (i.e. Pyxis)
 Bar Code Scanning
 Computerized Physician Order Entry
 Fostering an environment of safety –
improvement without blame
 The American Hospital Association lists the following as some
common types of medication errors:
 Incomplete patient information (not knowing about patients'
allergies, other medicines they are taking, previous diagnoses, and
lab results, for example)
 Unavailable drug information (such as lack of up-to-date
warnings);
 Miscommunication of drug orders- poor handwriting, confusion
between drugs with similar names, misuse of zeroes and decimal
points, confusion of metric and other dosing units, and
inappropriate abbreviations
 Lack of appropriate labeling as a drug is prepared and repackaged
into smaller units
 Environmental factors, such as lighting, heat, noise, and
interruptions, that can distract health professionals from their
medical tasks.
Medication Error Stats
 2.5 million deaths occur annually in the USA
 42% of people believed they had personally
experienced a medical mistake (NPSF
survey)
 44,000 to 98,000 deaths annually from
medical errors (Institute of Medicine)
 225,000 deaths annually from medical errors
including 106,000 deaths due to "non-error
adverse events of medications" (Starfield)
Medication Errors
 Annual cost of drug-related morbidity and
mortality is nearly $177 billion in the United
States
 180,000 deaths annually from medication
errors and adverse reactions (Holland)
 2.9 to 3.7 percent of hospitalizations leading
to adverse medication reactions
Medication Error Stats
• 7,391 deaths resulted from
medication errors (Institute of
Medicine)
• 2.4 to 3.6 percent of hospital
admissions were due to
(prescription) medication events
(Australian study)
Medication Error in Perinatal
Area
 According to the U.S. Pharmacopeia, Center
for the Advancement of Patient Safety
between 1998-2002 the of the 3,775
medication errors reported in three areas of
OB:
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Labor and Delivery = 49%
OB Recovery = 10%
Maternity Unit = 41%
Medication Errors
 76.7 % of those total errors reached the
patient but did not do harm
 70% of errors occurred during administration
of the medication
 3.2 % reached the patient and did significant
harm
 0.03% caused a death
Medication Errors
 Most common errors in Obstetrics
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Omission of the medication or missed doses
Improper dose / quantity
Unauthorized (unordered)
Wrong drug
Knowing absolute contraindications – i.e., an epidural on
a anti-coagulated patient
Wrong Timing
Extra doses
Wrong administration technique
Top 10 Causes of Medication
Errors in the Obstetrical Area
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Performance Deficit
Not following protocol or policy
Communication
Knowledge deficit
Documentation
Transcription error / omission
Dispensing device
System safeguards broke down
Improper use of pumps
Drug distribution systems
Drugs that are commonly
involved
 Over 300 total in all three areas
 Most common:
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Insulin
Antibiotics – Ampicillin, Cefazolin, Gentamycin
Magnesium Sulfate
Oxytocin – most frequently cited medication with adverse obstetrical
events that lead to professional liability claims
Prostaglandins – cervical ripening
Narcotics
Anticoagulants
Asthma Medications
Common Areas of Error
 Infusion pumps that are not programmed correctly
 Misconnected or disconnected IV tubing
 Administering medications or mainline fluids
through epidural catheter
 Omission of an antibiotic per protocol or order
 Lack of allergy information documented and patient
banded at the time of medication administration
 Incomplete communication and documentation
Prevention
 5 Rights – take the time to make sure you
do them EVERY time
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RIGHT MEDICATION/CONCENTRATION
RIGHT DOSE
RIGHT PATIENT
RIGHT TIME AND FREQUENCY (Even if double sign
off)
 RIGHT ROUTE
 Evelyn’s 6th Right*** RIGHT INDICATION
Documentation of Medication
Errors
 Adverse Reaction to Medication Form PRN
 Quality Improvement/Assurance Forms
 Chart – just the facts
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What you did
Who you notified
How the patient responded
Prevention of Infections
 Manage as sentinel
events all identified
cases of unanticipated
death or major
permanent loss of
function associated
with a health careassociated infection.
Reduce the risk of health careassociated infection
7. NPSG.07.01.01 -Comply with
current Centers for Disease Control
and Prevention (CDC) hand hygiene
guidelines.
 Hospitals in WA now
implementing programs were the
patients are asking the medical
staff if they have washed their
hands prior to touching them or
giving care and medications.
Reduce the Risk of Health
Care-Acquired Infections
8. NPSG.07.03.01 – Use guidelines to prevent
infections that are difficult to treat
9. NPSG.07.04.01 – Use guidelines to prevent
infection of the blood from central lines
10. NPSG.07.05.01 – Use proven guidelines to
prevent infection after surgery
11. NPSG.07.06.01- Use proven guidelines to prevent
infections of the urinary tract that are caused by
catheters
Reduce the Risk of Health CareAcquired Infections
 According to a report published in 2007 by
the CDC, “in American hospitals alone,
hospital acquired infections account for an
estimated 1.7 million infections and 99,000
associated deaths each year”
 Hospital-acquired infections are the sixth
leading cause of death nationally, costing the
health care industry $6 billion annually
MDRO
 Study reported in Consumer Affairs in 2005: Chicago's
Northwestern Memorial Hospital swabbed computer keyboards t
identify if any dangerous germs were present and for how long
they lived.
 Contaminated keyboards with three types of bacteria that can
cause life-threatening infections in severely ill hospital patients.
They found that the bacteria known as VRE (enterococcus) and
MRSA survived for at least 24 hours, while PSAE (pseudomonas)
bacteria survived for an hour.
 When volunteers tapped a key contaminated with MRSA, the
bacteria spread to their hands 92 percent of the time.
Contamination rates for lower for the other two bacteria -- 50
percent for VRE and 18 percent for PSAE.
MDRO
**A CDC study published in the current issue of the Journal of the American
Medical Association : MRSA - is much more prevalent than previously
thought. The study found MRSA cases tripled in the United States between
2000 and 2005, and estimated 94,360 people are infected and 18,650 die
annually, killing more people annually than HIV.
***A 2003 Centers for Disease Control and Prevention study:
52 percent of doctors did not clean their hands between patients.
Doctor's lab coat picked up MRSA bacteria 65 percent of the time when
leaning over an infected patient (1997)
77 percent of blood pressure cuffs on rolling carts were contaminated with
MRSA. (2007 study)
MDRO
According to the Centers for Disease Control, recent studies
place hand hygiene adherence in hospitals at between 29
percent and 48 percent.
Methicillin-resistant Staphylococcus aureus (MRSA),
can cost hospitals roughly $30,000 per case.
Brad Sokol, CEO of Fast Track Technologies, a health care
consulting firm, has estimated that our nation suffers 13,000
to 26,000 thousand deaths annually from infection caused by
contaminated medical devices and instruments.
Reduce Risk of Patient Harm
Resulting from Falls
 NPSG 09.02.01 – Reduce the risk of falls
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Implement a fall reduction program including an
evaluation of the effectiveness of the program
Identify Patient Safety Risks
12. NPSG.15.01.01 – Find out which patients are likely to try to commit
suicide
 Post partum depression = Post partum Complications
 Without treatment, depression can last for many months and may have
long-term consequences. Research suggests that postpartum depression
can interfere with bonding between mother and child, which can lead to
behavior problems and developmental delays when the child gets older.
Identify When there is a change in
the Patient’s Condition
 Develops criteria for calling additional assistance to
respond to a change in the patient’s condition or a
perception of change by the staff, the patient and/or
family
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Rapid Response
Codes
 Staff seek additional assistance when they have
concerns about a patient’s condition
 Formal education is done for urgent response
policies and practices
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Mock Codes
Prevent Mistakes in Surgery
13. UP.01.01.01- Make sure that the correct
surgery is done on the correct patient at the
correct place on their body
14. UP.01.02.01 – Mark the correct place on
the patient’s body where the surgery is done
15. UP.01.03.01 – Pause before the surgery to
make sure that a mistake is not being made
The organization Meets the
Expectation of the Universal
Protocol
 Verification of the correct person, site and procedure occurs
at the following times:
 When the procedure is scheduled
 Preadmission testing and assessment
 Admission or entry for procedure whether it is scheduled or
emergent
 Before leaves the pre-procedural area or enters the
procedure room
 Anytime responsibility for the care of the patient is
transferred to another member of the procedural care team at
the time of, and during, the procedure
 With the patient involved, awake and aware if possible
Pre-procedural Checklist
 Relevant documentation
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H&P
Nursing assessment
Pre-anesthesia assessment
 Accurately completed and signed consent form
 Correct diagnostic and radiology test results
 Any blood products, implants, devices and or
special equipment for the procedure
Pre-Procedural Time Out
 Conducted prior to starting the procedure and ideally,
prior to induction of anesthesia, unless contraindicated
 Standardized
 Initiated by a designated member of the team
 Involves the immediate members of the procedure team
 Involves interactive verbal communication between all
team members
Pre-Procedural Time Out
 Includes a defined process for reconciling
differences in responses
 During time out all other activities are suspended
(as long as it does not compromise patient safety)
 If two or more procedures are being performed on
the same patient, a time out is performed to confirm
each subsequent procedure before it is initiated
Pre-Procedural Time Out
 Addresses the following:
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Correct patient
Confirmation that side and site are marked
Accurate procedure consent
Agreement of procedure to be performed
Correct patient position
Relevant images, diagnostic tests and results are properly
labeled and displayed
The need to administer antibiotics or fluids
Special equipment or supplies
Safety precautions based on the patients current
medications or history
Marking the Procedure Site
 Performed by a Licensed Independent
Provider credentialed to perform procedure
 Marked while patient is awake if possible
 Marked prior to going into procedural room
Marking of the Side and Site for
OB
 OB is excepted on most side and site marking:
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C-sections
D & C and D & E
Vaginal Delivery
Cerclage
Hysterectomy
Bilateral Tubal Ligation
Circumcisions
*** Exception – UNILATERAL tubal or ovary
surgery
Sentinel Events
 Organization is placed on an “Accreditation Watch” when a
sentinel event has occurred and has come to the Joint’s attention
 Adverse Drug Event
 Adverse Event
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Death of a patient (unexpected)
Retained foreign object
Patient Falls
Perforation, hemorrhage, bacteremia, complications to anesthesia or
sedation
Any complication that leads to undesirable outcomes
Any adverse/undesirable outcomes that result from providers or health care
staff that result in an illness or injury
Errors of commission or omission that result in patient severe or permanent
injury
Bariatric Patients
 Special Population that has additional safety
risks for Obstetrics
Body Mass Index (BMI)
 Correlates but does not directly measure
body fat
 Calculated from weight and height
 Correlates with body fat that is measured by
underwater and x-ray absorptiometry
methods
 Cheaper, more efficient and more readily
available method of measurement to the
medical practitioner
BMI
BMI
Weight Category
<18.5
Underweight
18.5-24.9
Normal
25.0-29.9
Overweight
30-39.9
Obese
> 40
Extremely (Morbidly)
Obese
Statistics
 More than one-third of U.S. adults (35.7%)
are obese.
 Non-Hispanic blacks have the highest ageadjusted rates of obesity (49.5%) compared
with Mexican Americans (40.4%), all
Hispanics (39.1%) and non-Hispanic whites
(34.3%) JAMA. 2012;307(5):491-497.
doi:10.1001/jama.2012.39.
US Statistics
 In 2008, medical costs associated with obesity were
estimated at $147 billion
 Medical costs for people who are obese were
$1,429 higher than those of normal weight
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1998, 2006
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1998
1990
2006
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
United States 2011 Obesity
Rates
Adult Women Affected by Obesity
 49% of Non-Hispanic African American
Women
 38% of Hispanic Women
 31% Non-Hispanic Caucasian Women
Medical Conditions and Obesity
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Sleep Apnea
Hypertension
Malnutrition
Type II Diabetes
Coronary Heart Disease
Strokes
Gallbladder Disease
Osteoarthritis
Cancer
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Endometrial
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Breast
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Colon
Obstetrical Risk Factors and Obesity
Diabetes
 Type II
 Gestational
Spontaneous Abortion
Preclampsia
Gestational Hypertension
Fetal Macrosomia
Obstetrical Risk Factors and Obesity
Cesarean Birth (related to failure to progress)
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20.7% if BMI <30
33.8% if BMI 30-34.9
47.4% if BMI 35-39.9
Shoulder dystocia
Prenatal Assessment
 Early Diabetes Screening
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On first or second OB visit
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Again at 24-28 weeks
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Use 50 Gram glucose tolerance test (GTT)
 Nutrition consult
 Assessment for vitamins, nutrients
 Weight management during pregnancy
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Normal weight gain 25-35 lbs for the
“normal” weight patient
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Overweight patient gain 15-25 lbs
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15 lbs for the obese patient
Intrapartum Issues
 May be difficult to:
Obtain accurate estimated fetal weight
Perform Leopold's maneuver
Monitor fetal well being and uterine activity
Find the right equipment – size, fit, weight restrictions
Hill-Rom Affinity bed = 500 lbs
Foot of the bed = 400 lbs
Find medical staff members with knowledge of how to care for
patient with her particular needs
Nursing Care Issues
 Sue Yager 1600 lbs
Nursing Care Issues
 Prejudice
 Require EARLY anesthesia consult regarding pain
management and surgical planning
 Medication Management
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May require more antibiotics per kilogram
weight – need to check with pharmacy
Require antibiotics 30 minutes PRIOR to surgery
Requires longer needles for IM injections – 2
inch to 2 ½ inch
May react to pain medications differently – take
longer to clear (due to increased fat storage)
Surgical Management Considerations
 Airway management
 Preoperative showering for c-section with chlorhexidine (48
hour kill rate)
 Potential for excessive blood loss
 Anesthesia challenges for induction
 Increased operative time
 Large panis
 Increased time to close
 Operative Beds
 Regular beds – 400 lbs
 “Hercules” table – 800-1000 lbs (better hydraulics)
Surgical Management Considerations
 5-15% Complication
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Wound dehiscence
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Wound infection
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Poor wound healing
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Endometritis
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Deep Vein Thrombosis (DVT)
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Pulmonary Edema
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Pulmonary Emboli
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Pneumonia
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Sleep apnea – respiratory depression
Surgical Wound
Surgical Wound
Post Operative Issues
 Wounds may be left open
 Vertical exterior wounds
 JP drains
 Consideration of whether need PACU
recovery and ICU stay
Moving Bariatric Patients
 Good body mechanics
No holding legs for 2nd stage!!!!
 Team approach – 3-4 Lift team
 Right Equipment
 Hover mats
 Lifts – KCI 1000 lbs
 Stretchers
Stryker 1710 = 500 lbs
Wyeast = 600 lbs
Stryker Bariatric = 660 lbs
Other Equipment
 Hill-Rom VersaCare Bed – Up to 600 Lbs
and can convert to a chair (costs about
$7,500)
Other Equipment
 Wall mounted toilets only hold 250-300 lbs
 Commodes – regular commode holds 250 lbs
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Bariatric commode 750-800 lbs and need to
provide privacy measures (costs about $300)
Bariatric Weight Loss Procedures
Bariatric Weight Loss Procedures
Multiple Bariatric Weight Loss Procedures are
surgically available now.
Some will impact pregnancy more than others
Adjustable Gastric Banding
Roux-en-Y Stomach Bypass
Biliopancreatic Diversion
(BPD)
Biliopancreatic Diversion with Duodenal Switch
Dumping Syndrome
Post Bariatric Surgery and Pregnancy
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Nutrition
Absorption
Fetal growth and development
Recommendation is to wait 12-24 months after surgery
Pregnancy less likely to be complicated by:
 Gestational or Type II Diabetes
 Hypertension
 Fetal Macrosomia
 Cesarean birth
Patient Satisfaction Surveys
 Working toward the JCAHO Safety Goals
 The Ideal Patient Experience:
Positive Attitude
Sense of Ownership & Accountability
Collaboration & Participation-Pt centered
care
Organizational/Nursing Actions
That Lead to Improved Patient
Outcomes
 Positive Attitude
 Sense of Ownership and Accountability
 Collaboration & Participation in Patient &
Family Centered Care
 Information sharing – keeping the patient informed
in a language that they understand
 Follow up and see if they have any other questions
or needs
Opportunities for Improvement in
Patient Care
 Increase trust
 Increase confidence
 Continuity of care
 Explaining procedures
 Emotional support
 Treating patients with respect and dignity
Ideal Patient Experience
 Hospitals are now looking at patient
satisfaction surveys as part of their
Continuous Quality Improvement (CQI)
process
 Looking for ways to improve the patient care
experience
Organizational/Nursing Actions
That Lead to Improved Patient
Outcomes






Practice good telephone etiquette
Have professional and appropriate appearance
Perform random acts of kindness
Provide smooth transitions – patient handoffs
Provide safe, age appropriate, and comfortable care
Appreciate and celebrate staff for jobs well done
References
 BRFSS, Behavioral Risk Factor Surveillance System
http: //www.cdc.gov/brfss/
 Mokdad AH, et al. The spread of the obesity epidemic in the
United States, 1991—1998 JAMA 1999; 282:16:1519–1522.
 Mokdad AH, et al. The continuing epidemics of obesity and
diabetes in the United States. JAMA. 2001; 286:10:1519–22.
 Mokdad AH, et al. Prevalence of obesity, diabetes, and
obesity-related health risk factors, 2001. JAMA 2003: 289:1:
76–79
 CDC. State-Specific Prevalence of Obesity Among Adults
— United States, 2005; MMWR 2006; 55(36);985–988
References
 JCAHO 2013 National Patient Safety Goals
 JCAHO News release 1/27/2005, “Speak Up: New National
Campaign Offers America To Prevent Medication Mistakes”
 Maxfield, D., Grenny, J., McMillan, R., Patterson, K., &
Switzer, A. Vitalsmarts Industry Watch, Executive
Summary (2005). Silence Kills: The Seven Crucial
Conversations in Healthcare.
 U.S. Pharmacopeia, edited version of AWHONN Lifelines
(April/May 2004) Errors in Obstetrics.