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Patient Safety Research Highlights

Program Brief

The Agency for Healthcare Research and Quality (AHRQ) has long been committed to systematically studying patient safety in medical practice, funding more than 100 studies since 2001. Brief descriptions of the tools and findings of the research are presented here.

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Introduction
Fatigue and Patient Safety
Technology
Event Reporting
Medication Safety
Communication and Patient Support
Clinical Practice Change
Organizational Change
Education and Training
Safety in Intensive Care Units
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Introduction

Medical errors are a serious problem in health care and a major concern to patients as well as to the health care industry. The Agency for Healthcare Research and Quality (AHRQ) has long been committed to a systematic approach to the issue of patient safety in medical practice. As the lead agency within the U.S. Department of Health and Human Services working to prevent errors and improve patient safety, AHRQ's goal is to reduce the potential of patient harm by promoting and supporting research.

Since fiscal year 2001, AHRQ has funded more than 100 patient safety projects. The investigators for these projects worked on different aspects of patient safety, ranging from system-wide event reporting methods to specific measures to minimize known medical errors in particular situations. Many of these studies produced new findings, tools, and products that can be used by the health care system, health care providers, and researchers to improve patient safety. Brief descriptions of these tools and findings (typically published in journal articles) are presented within the following categories:

Fatigue and Patient Safety.
Technology.
Event Reporting.
Medication Safety.
Communication and Patient Support.
Clinical Practice Change.
Organizational Change.
Education and Training.
Safety in Intensive Care Units (ICUs).

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Fatigue and Patient Safety

Medical interns who work extended-duration shifts double their risk of car crashes when driving home from the hospital. First-year doctors in training, or medical interns, who work shifts longer than 24 hours are more than twice as likely to have a car crash leaving the hospital and five times as likely to have a "near miss" incident on the road as medical interns who work shorter shifts. The article reporting this finding is among a series of studies on the impact of extended work hours and fatigue on interns conducted by the Divisions of Sleep Medicine at the Brigham and Women's Hospital and the Harvard Medical School in Boston. All three studies were co-funded by AHRQ and the Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health.
Project Title: Effects of Extended Work Hours on ICU Patient Safety
Research Area: WC
AHRQ Grant: HS12032
Principal Investigator: Charles Czeisler, M.D.
Reference: Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, Czeisler CA. Harvard Work Hours, Health, and Safety Group. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 2005 Jan 13;352(2):125-34.

Sleep deprivation affects clinical performance of medical interns, surgical residents, and anesthesiologists. Patient care may be compromised if a fatigued, sleep-deprived clinician is allowed to operate, administer an anesthetic, manage a medical crisis, or deal with an unusual or cognitively demanding clinical case. AHRQ researchers reviewed the consequences of sleep loss in controlled laboratory environments and in clinical studies involving medical personnel. Sleep-deprived medical interns performed poorly; detected fewer cardiac arrhythmias; and complained of feeling sad, fatigued, and unsure of themselves when compared with rested interns. With increasing sleep loss, surgical residents were slower and made more errors in a virtual reality simulation of laparoscopic surgery. Sleep-deprived anesthesiologists needed more time to accomplish routine tasks in actual patient care settings, and some anesthesiologists fell asleep while administering anesthesia in a simulation study.
Project Title: Standardized Encounters to Study Patient Safety
Research Area: DCERPS
AHRQ Grant: HS11521
Principal Investigator: Matthew B. Weinger, M.D.
Reference: Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA 2002 Feb 27;287:955-7.

Suggestions to help sleep-deprived night shift nurses avoid impaired performance. Night shift nurses are usually sleep-deprived and may have impaired performance, miss subtle signs of patient deterioration, and fail to detect medication errors. AHRQ researchers suggest some tools to counter this problem, such as avoiding back-to-back shifts, limiting overtime, allowing nurses to sleep for 15 to 30 minutes during breaks, and providing them a safe place to sleep before driving home.
Project Title: Staff Nurse Fatigue and Patient Safety
AHRQ Grant: HS11963
Research Area: WC
Principal Investigator: Ann Rogers, R.N.
Reference: Rogers AE. Sleep deprivation and ED night shift. J Emerg Nurs 2002 Oct 28;28:469-70.

Risk of nursing errors does not appear to be improved by work breaks. Staff nurses frequently skip their breaks and/or meal periods to provide patient care. In an AHRQ-funded study, 393 nurses completed logbooks for 28 days, providing information about their work hours, errors, and episodes of drowsiness and actual sleep on duty. Participants were asked if they were able to take a break or sit down for a meal during their shift, to indicate the total duration of breaks taken during the shift, and if they were relieved of patient care responsibilities during their meals and/or break periods. Nurses reported having a break or meal period free of patient care responsibilities during fewer than half of the shifts they worked. There were no differences in the risk of errors reported by nurses who had a break free of patient care responsibilities compared with those who were unable to take a break.
Project Title: Staff Nurse Fatigue and Patient Safety
AHRQ Grant: HS11963
Research Area: WC
Principal Investigator: Ann Rogers, R.N.
Reference: Rogers AE, Hwang WT, Scott LD. The effects of work breaks on staff nurse performance. J Nurs Adm 2004 Nov;34(11):512-9.

Serious medical errors in ICUs can be reduced when traditional 30-hour-in-a-row extended work shifts are eliminated. The rate of serious medical errors committed by first-year doctors in training (interns) in two ICUs at a Boston hospital fell significantly when traditional 30-hour-in-a-row extended work shifts were eliminated, and the number of hours worked per week was reduced. AHRQ researchers found that interns made 36 percent more serious medical errors, including five times as many serious diagnostic errors, on the traditional schedule than on an intervention schedule that limited continuous work shifts to 16 hours and reduced scheduled weekly work from approximately 80 hours to 63. The rate of serious medication errors was 21 percent greater on the traditional schedule than on the new schedule.
Project Title: Effects of Extended Work Hours on ICU Patient Safety
AHRQ Grant: HS12032
Research Area:WC
Principal Investigator: Charles Czeisler, M.D.
Reference: Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004 Oct 28;351(18):1838-48.

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Technology

Information technology provides an inexpensive method for detecting certain types of adverse events. Most health care organizations rely on spontaneous reporting, which detects only a fraction of adverse events. As a result, problems with safety may remain hidden. AHRQ researchers reviewed methodologies for detecting adverse events using information technology and found that tools such as event monitoring and natural language processing can inexpensively detect certain types of adverse events such as adverse drug events and nosocomial infections in clinical databases.
Project Title: Improving Quality with Outpatient Decision Support
Research Area: TRIP-II
AHRQ Grant: HS11046
Principal Investigator: David Bates, M.D.
Reference: Bates DW, Evans RS, Murff H, Stetson PD, Pizziferri L, Hripcsak G. Detecting adverse events using information technology. J Am Med Inform Assoc 2003 Mar-Apr;10(2):115-28.

Computerized order entry can lead to an increased probability of medication errors. While computerized physician order entry (CPOE) is expected to significantly reduce medication errors, systems must be implemented thoughtfully to avoid facilitating certain types of errors. AHRQ researchers identified 22 situations in which a CPOE system increased the probability of medication errors. According to the study, these situations fell into two categories: information errors generated by fragmentation of data and hospitals' many information systems, and interface problems between humans and machines, where the computer's requirements were different than the way clinical work is organized. The study looked at clinicians' experience in using one CPOE system at a major urban teaching hospital.
Project Title: Improving Patient Safety by Reducing Medication Errors
Research Area: COE
AHRQ Grant: HS11530
Principal Investigator: Brian Strom, M.D.
Reference: Koppel R et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005 Mar 9;293:1197-203.

New tool mines complex clinical data to detect and investigate targeted adverse patient safety events. Given the volume of patients seen at medical centers, detecting adverse events automatically from data already available electronically can greatly facilitate patient safety work. AHRQ researchers have created a tool for electronic detection of events in medical records that allows for selecting target events, assessing what information is available electronically, transforming raw data such as narrative notes into a coded format, querying the transformed data, verifying the accuracy of event detection, characterizing the events using systems and cognitive approaches, and using what is learned to improve detection. Adoption of standard terminology and standard clinical document architecture may improve the performance and generalizability of the tool.
Project Title: Mining Complex Clinical Data for Patient Safety Research
Research Area: CLIPS
AHRQ Grant: HS11806
Principal Investigator: George Hripcsak, M.D.
Reference: Hripcsak G, Bakken S, Stetson PD, Patel VL. Mining complex clinical data for patient safety research: a framework for event discovery. J Biomed Inform 2003 Feb-Apr;36(1-2):120-30.

Information technology saves time for intensive care unit nurses by reducing the burden of documentation. ICU information systems can save documentation time for nurses, potentially freeing up nursing time for direct patient care. AHRQ researchers determined the percentage of time that ICU nurses spent on documentation and other nursing activities before and after installation of a third-generation ICU information system. They found that the information system decreased the time ICU nurses spent on documentation by more than 30 percent. Almost half of the time saved on documentation was spent on patient assessment, a direct patient care task.
Project Title: Standardized Encounters to Study Patient Safety
Research Area: DCERPS
AHRQ Grant: HS11521
Principal Investigator: Matthew B. Weinger, M.D.
Reference:Wong DH, Gallegos Y, Weinger MB, Clack S, Slagle J, Anderson CT. Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system. Crit Care Med 2003 Oct;31(10):2488-94.

Computer-based order entry can reduce catheter-related urinary tract infections. Up to 25 percent of hospitalized patients undergo urinary catheterization and catheter-related urinary tract infections are very common. Frequently, the catheters are left in place longer than necessary because of poor documentation. AHRQ researchers developed a computer-based order entry form that provides routine catheter care instructions and indicates catheter removal after 72 hours by default. This computer-based order entry decreased the duration of catheterization by about one-third, or 3 days.
Project Title: Targeting Interventions to Reduce Errors
Research Area: DCERPS
AHRQ Grant: HS11540
Principal Investigator: Timothy Hofer, M.D.
Reference: Cornia PB, Amory JK, Fraser S, Saint S, Lipsky BA. Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients. Am J Med 2003 Apr 1;114(5):404-7.

Computer software helps detect patients who are most prone to falling or developing bed sores. AHRQ researchers have used New York State longitudinal data to demonstrate the utility of a Web-based management reporting system in long-term care settings. With the reporting system, researchers developed risk assessment models that predict probabilities of adverse events. Facilities have reported tremendous time saving, and some facilities have abandoned manual risk assessment tools altogether in favor of the system. One 300-bed nursing home in New York State steadily reduced the number of falls among its patients, going from 93 incidences in September 2002 to 53 in February 2003. Another New York nursing home using the system received a $30,000 reduction in its annual liability insurance premium. In addition, both 2005 patient safety awards by the New York State Department of Health went to nursing homes using the new technology.
Project Title: Using Prospective MDS Data to Enhance Resident Safety
Research Area: CLIPS
AHRQ Grant: HS11869
Principal Investigator: Christie Teigland, Ph.D.
Reference: Teigland C, Gardiner R, Li H, Bryne C. Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure Ulcers in Nursing Home Environments. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation. Vol. 3, Implementation Issues. AHRQ Publication Number 05-0021-3. Rockville, MD: Agency for Healthcare Research and Quality; Feb. 2005. pp. 69-85. Article accessible at: Government Health IT (http://www.governmenthealthit.com/article90512-08-29-05-Web).

Natural language processing (NLP) may be effective in detecting adverse events. AHRQ researchers programmed an NLP system that translates narrative clinical notes into an electronically coded form. They used the system to process 2 years of inpatient medical charts with electronic discharge summaries from an urban, tertiary health care institution. Researchers found that NLP was three times more sensitive in detecting adverse events than traditional reporting, without complicating clinicians' routine work processes. Among NLP's potential health care applications, AHRQ researchers highlight the feasibility of nationwide screening for adverse events.
Project Title: Mining Complex Clinical Data for Patient Safety Research
Research Area: CLIPS
AHRQ Grant: HS11806
Principal Investigator: George Hripcsak, M.D.
Reference: Melton GB, Hripcsak G. Automated detection of adverse events using natural language processing of discharge summaries. J Am Med Inform Assoc 2005 Jul-Aug;12(4):448-57.

Information technology design should keep end-users in mind. Electronic infusion pumps are widely used in hospitals throughout the U.S. to manage the administration of intravenous medications. However, AHRQ researchers found that difficulties often arise from poor coordination between the operator and the infusion pump as a result of interface design, leading to improper use. Infusion pumps often involve multiple modes of operation, substantial operator programming, and contain layered menus with complex branching schemes that present difficulties for health care providers. Practitioners must perform additional work to coordinate care and program the devices. The additional cognitive work involved in programming these devices presents unforeseen complications, such as adverse drug events, that can affect patient safety. For IT equipment and systems to support safe health care, there must be a coordination between human and machine.
Project Title: Linking User Error to Lab and Field Study of Medical IT
Research Area: CLIPS
AHRQ Grant: HS11816
Principal Investigator: Richard Cook, M.D.
Reference: Nemeth C, Nunnally M, O'Connor M, Klock PA, Cook R. Getting to the point: developing IT for the sharp end of healthcare. J Biomed Inform 2005 Feb;38(1):18-25. Article available at: http://www.ctlab.org/documents/Getting%20to%20the%20Point.pdf.

Software can be integrated into geriatric care to prevent adverse events. AHRQ researchers evaluated the capacity of information technology, specifically software developed by the American Society of Consultant Pharmacists (ASCP) Research and Education Foundation, to prevent delirium and falls. The software is intended to assist in identifying problems in nursing homes during the monitoring stage of the medication use process. Researchers were successful in integrating the software with pharmacy workflow, and it aided the development of Medication Monitoring Care Plans and Flow Records for falls and delirium. In addition, preliminary results demonstrate acceptance of the software and the feasibility of incorporating a clinical informatics tool into the pharmaceutical care process.
Project Title: Pharmacist Technology for Nursing Home Resident Safety
Research Area: CLIPS
AHRQ Grant: HS11835
Principal Investigator: Kate Lapane, PhD
Reference: Lapane KL, Cameron K, Feinberg J. Technology for improving medication monitoring in nursing homes. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation. Vol. 4, Programs, Tools, and Products. AHRQ Publication Number 05-0021-4. Rockville, MD: Agency for Healthcare Research and Quality; Feb. 2005. pp. 401-13.

*Design of computerized alerts affects whether physicians heed or override CPOE guidance. To guide the design of effective medication safety alerts in clinical decision support systems in the outpatient setting. AHRQ researchers conducted in-depth interviews with primary care prescribers from a Pacific Northwest health maintenance organization (HMO). The researchers' goal was to determine what alert characteristics are most likely to elicit positive emotional and clinical responses from prescribers. The findings are that clinicians prefer alerts that are clear, speak to unfamiliar topics, provide links to supporting evidence, and are related to patient safety (such as drug interactions, allergies, and dosing).
Project Title: The CERTs Prescribing Safety Program
Research Area: R-DEMO
AHRQ Grant: HS11843
Principal Investigator: Richard Platt, M.D., M.Sc.
Reference: Feldstein A, Simon SR, Schneider J, Krall M, Laferriere D, Smith DH, Sittig DF, Soumerai SB. How to design computerized alerts to ensure safe prescribing practices. Jt Comm J Qual Pat Saf 2004 Nov;30(11):602-13.

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Event Reporting

Hospital leaders are concerned about mandatory error reporting because it discourages staff from reporting and encourages lawsuits. A survey of hospital leaders found that nearly 70 percent believed that a nonconfidential, mandatory system would discourage staff from reporting patient safety incidents to their hospitals' own internal reporting system, and almost 80 percent thought it would encourage lawsuits. The researchers also found that more than 80 percent felt the names of both the hospital and involved staff members should be kept confidential, although respondents from States with mandatory, nonconfidential systems already in place were more willing to have hospital names released. Over 90 percent said their hospital would report serious injuries to their State hospital licensing agencies, but far fewer would report moderate or minor injuries. However, the hospital leaders surveyed generally did favor disclosing patient safety incidents to patients who were involved.
Project Title: Evaluate the Effects of Massachusetts Reporting System
AHRQ Grant: HS11928
Principal Investigator: Nancy Ridley, M.D.
Reference: Weissman JS, Annas CL, Epstein AM, Schneider EC, Clarridge B, Kirle L, Gatsonis C, Feibelmann S, Ridley N. Error reporting and disclosure systems: views from hospital leaders. JAMA 2005 Mar 16;293(11):1359-66.

Reporting system developed to gather valuable information on close calls also facilitates the use of targeted interventions. The University of Texas Close Call Reporting System is a voluntary and anonymous tool designed to gather valuable information about close calls, situations in which an accident, injury, or illness could have resulted, but was averted due to chance or a timely intervention. Information from close call reports also facilitates the development of targeted interventions and ultimately leads to the identification and implementation of best practices in quality improvement. The tool's flexible design allows for potential adaptation and use by others. The Web site for the reporting system and training is accessible at http://www.utccrs.org/ccrs/
Project Title: Translating Safety Practices from Aviation to Healthcare
Research Area: COE
AHRQ Grant: HS11544
Principal Investigator: Eric Thomas, M.D.

Anonymous event reporting tool allows hospitals to report errors without worry. The Partnership for Health and Accountability of the Georgia Hospital Association has created an online anonymous event reporting tool that can serve as a model for hospitals to voluntarily report medical errors. The Web site is at http://www.gha.org/pha/ and the tool at http://www.gha.org/pha/patientsafety/event_reporting/index.asp#live.
Project Title: Accountability and Health Safety, a Statewide Approach
Research Area: R-DEMO
AHRQ Grant: HS11918
Principal Investigator: Kenneth Thorpe, Ph.D.

The University of Mississippi Medical Center (UMMC) has implemented a new, Web-based, occurrence reporting system. The occurrence reporting system is divided into two sections: (1) general reporting (i.e., falls and unsafe conditions) and (2) medication error reporting. Since implementing the reporting system, significant changes in the process and level of reporting have been observed. Prior to its introduction, approximately 30 general and medication-related reports were received per month. In comparison, in the first 3 months of using the Web-based reporting system, 658 reports were received. These reports are received on a near real-time basis, allowing for immediate action to be taken when required. A public version of the patient safety reporting Web site is available. at: http://www.medicinematters.org.
Project Title: Addressing Preventable Medication Use Variance in Mississippi
Research Area: R-DEMO
AHRQ Grant: HS11923
Principal Investigator: C. Andrew Brown, M.D., M.P.H
Reference: Rudman WJ, Bailey JH, Hope C, Garrett P, Brown CA. The impact of a Web-based reporting system on the collection of medication error occurrence data. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation. Vol. 3, Implementation Issues. AHRQ Publication Number 05-0021-3. Rockville, MD: Agency for Healthcare Research and Quality; Feb. 2005. pp. 195-205.

Intensive Care Unit reporting system available to the public. A fully functioning version of the Intensive Care Unit Safety Reporting System (ICUSRS) data input form is available for inspection at http://www.icusrs.org. The ICUSRS is a Web-based, anonymous, and confidential reporting form for ICU staff to report adverse events and near misses. Eighteen ICUs submitted a total of 854 reports to the ICUSRS during the first year of the project. AHRQ researchers found that a diverse group of ICUs will submit events, and conclude that the ICUSRS helps to identify rare events and lessons learned that can be shared among ICUs.
Project Title: Intensive Care Unit Safety Reporting System
Research Area: R-DEMO
AHRQ Grant: HS11902-03
Principal Investigator: Peter Pronovost, M.D., Ph.D.
Reference: Holzmueller CG, Pronovost PJ, Dickman F, Thompson DA, Wu AW, Lubomski LH, Fahey M, Steinwachs DM, Engineer L, Jaffrey A, Morlock LL, Dorman T. Creating the Web-based intensive care unit safety reporting system. J Am Med Inform Assoc 2005 Mar-Apr;12(2):130-9.

*Mandatory medication error reporting and root cause analysis identifies systems that contribute to errors and strategies for improvement. A multidisciplinary panel of experts analyzed 24 months of medication errors reported to the New York Patient Occurrence Reporting and Tracking System (NYPORTS). Near-death errors (48%) and errors leading to death (23%) accounted for nearly three-fourths of all 108 medication errors reported—occurring most frequently as wrong dose, wrong drug, and administration errors. The chance for injury was greatest while transitioning patients across care, managing complex dosing regimens, and in tightly coupled systems—such as ICUs or EDs. In tightly coupled systems there is little buffer or slack between the action and its outcome; such systems pose a threat of harm because there is often little time to detect an error. Researchers describe individual cases of medication errors, and both successful and unsuccessful system fixes implemented by hospitals. They conclude that solutions must address the system, not the situation; and shortfalls in practitioner memory must be overcome not through posterror education, but through prompts (such as preprinted order sheets for anticoagulant drugs) requiring practitioners to consider critical information at the time of ordering medications.
Project Title: New York State Safety Improvement Demonstration Project
Research Area: R-DEMO
AHRQ Grant: HS11880
Principal Investigator: Ellen Flink, M.B.A.
Reference: Duthie E, Favreau B, Ruperto A, Mannion J, Flink E, Leslie R. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation. Vol. 1, Research Findings. AHRQ Publication Number 05-0021-4. Rockville, MD: Agency for Healthcare Research and Quality, Feb. 2005. pp. 131-44.

*Surveillance of medical injuries is possible using screening criteria based on International Classification of Diseases (ICD-9-CM) diagnostic codes. AHRQ researchers assessed the validity of using ICD-9-CM E- and N-code diagnoses in hospital discharge data to identify medical injuries. The screening criteria had good sensitivity (59.9 percent) and good specificity (97.4 percent) when compared to medical record review, the gold standard of adverse event identification. ICD-9-CM E-codes were substantially more useful for identifying injuries related to drugs and radiation, and N-codes were more useful for identifying injuries linked to medical or surgical procedures, and devices, implants, or grafts.
Project Title: Improving Patient Safety: Health Systems Reporting
Research Area: R-DEMO
AHRQ Grant: HS11893
Principal Investigator: Peter M. Layde, M.D., M.Sc.
Reference: Layde PM, Meurer LN, Guse C, Meurer JR, Yang H, Laud P, Kuhn EM, Brassel KJ, Hargarten SW. Medical Injury Identification Using Hospital Discharge Data. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation. Vol. 2. Concepts and Methodology. AHRQ Publication Number 05-0021-4. Rockville, MD: Agency for Healthcare Research and Quality, Feb. 2005. pp. 119-32.

*Wrong-site surgery is extremely rare and often preventable. AHRQ researchers found that besides occurring rarely, wrong-site surgery rarely results in serious injury—resulting in a report to insurance risk managers or in a lawsuit approximately once every 5-10 years at a single large hospital. The study assessed all wrong-site surgeries reported to a large medical malpractice insurer between 1985 and 2004, and found that wrong-site surgeries conducted on limbs or organs other than the spine occurred once in every 112,994 operations. Forty cases of wrong-site surgery were identified among 1,153 malpractice claims and 259 instances of insurance loss related to surgical care. Twenty-five of the cases were non-spine wrong-site surgeries, with the remainder involving surgery of the spine. The study examined site-verification protocols at 25 hospitals as a means to prevent wrong-site surgery from occurring. The study found that simplicity and avoidance of excessive redundancy are the key features of successful site-verification protocols.
Project Title: Malpractice Insurers' Medical Error Prevention Study
Research Area: R-DEMO
AHRQ Grant: HS11886
Principal Investigator: David M. Studdert, LL.B., Sc.D.
Reference: Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg 2006 Apr; 141(4):353-7.

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