Research Methods

HEALTH CARE POLICY AND SYSTEMS

1

Key words Patient safety, quality improvement,

evidence-based practice, medication

administration errors, intervention research,

focus group, drug round tabard

Accepted: May 3, 2014

doi: 10.1111/jnu.12092

Abstract

Background: The use of drug round tabards is a widespread intervention that is implemented to reduce the number of interruptions and medication admin- istration errors (MAEs) by nurses; however, evidence for their effectiveness is scarce. Purpose: Evaluation of the effect of drug round tabards on the frequency and type of interruptions, MAEs, the linearity between interruptions and MAEs, as well as to explore nurses’ experiences with the tabards. Study Design: A mixed methods before-after study, with three observation periods on three wards of a Dutch university hospital, combined with personal inquiry and a focus group with nurses. Methods: In one pre-implementation period and two post-implementation periods at 2 weeks and 4 months, interruptions and MAEs were observed dur- ing drug rounds. Descriptive statistics and univariable linear regression were used to determine the effects of the tabard, combined with personal inquiry and a focus group to find out experiences with the tabard. Findings: A total of 313 medication administrations were observed. Signifi- cant reductions in both interruptions and MAEs were found after implemen- tation of the tabards. In the third period, a decrease of 75% in interruptions and 66% in MAEs was found. Linear regression analysis revealed a model R2

of 10.4%. The implementation topics that emerged can be classified into three themes: personal considerations, patient perceptions, and considerations re- garding tabard effectiveness.

The possible effect of medication errors (MEs) on pa- tient safety raises concerns for healthcare safety boards

worldwide. In reaction to this problem, boards incorpo- rate quality items and safety goals into their programs

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that require action by the hospitals (Institute for Safe Medication Practices, 2014; World Health Organization High 5, 2014).

Literature indicates that the ME rate may vary from 5% to 25% in all episodes of in-hospital drug admin- istration, but only 19% are reported (Antonow, Smith, & Silver, 2000; Krahenbuhl-Melcher et al., 2007; West- brook, Woods, Rob, Dunsmuir, & Day, 2010). This could indicate that the actual incidence rates might be higher. Therefore, MEs endanger the safety of patients. MEs occur in every stage of the medication process, with 50% of them associated with medication administration (Krahenbuhl-Melcher et al., 2007). In hospitals, nurses are generally responsible for this stage in the medication process.

In general, interruptions or distractions are recognized to reduce efficiency and contribute to errors (Brixey et al., 2007). In specific, interruptions appear to be a promi- nent causative factor for medication administration er- rors (MAEs; Biron, Loiselle, & Lavoie-Tremblay, 2009; Freeman, McKee, Lee-Lehner, & Pesenecker, 2012; Tr- bovich, Prakash, Stewart, Trip, & Savage, 2010; West- brook et al., 2010).

The literature describes several initiatives that in- fluence nursing medication practice to reduce MAEs (Hodgkinson, Koch, Nay, & Nichols, 2006; Raban & Westbrook, 2013). One of these interventions includes tabards, or vests, with the inscription “do not disturb” or visible signage.

The use of drug round tabards is a widespread, in- expensive intervention that is thought to reduce the number of interruptions during drug rounds and MAEs. However, in practice the tabards are unpopular among nurses; they doubt their effectiveness and do not feel comfortable wearing them. Additionally, the evidence on effectiveness of using tabards is limited (Raban & Westbrook, 2013; Scott, Williams, Ingram, & Mackenzie, 2010). When evidence is lacking, the incentive to wear a tabard will be especially weak and one can become re- luctant to implement interventions (Glasziou, Ogrinc, & Goodman, 2011; Smeulers, Onderwater, van Zwieten, & Vermeulen, 2014). If the effectiveness of these tabards can be established and barriers and facilitators can be identified, implementation in clinical practice will be fa- cilitated and endorsed. Therefore, the aim of our study is to evaluate the effect of drug round tabards on (a) the frequency and type of interruptions, (b) the number and type of MAEs, and (c) the magnitude of the relation between interruptions and MAEs during the process of preparation, distribution, and administration of medica- tion in hospital wards. In addition, we explored nurses’ perspectives and experiences with drug round tabards to identify barriers and facilitators for implementation.

Methods

Setting

Three wards in a Dutch 1,024-bed university hospi- tal contributed to this study: neurology, neurosurgery, and a combined ward with dermatology, ophthalmol- ogy, and ENT services. In total, these wards contain 60 beds. Each ward has a closed medication storage and preparation room where medication carts are stored for use during drug rounds. These carts are equipped with drawers and files containing computer-printed medica- tion prescriptions for each patient. All oral medications are distributed for 24 hr and are checked once by the ward’s night shift. Fluids, intravenous medications, and other medications for injection are prepared and double- checked during each drug round directly before drug ad- ministration.

Population

The participants were all registered nurses. Each had an individual responsibility for distributing medications to their assigned patients.

Study Design

We performed a mixed method study, using a before- after design to collect the number of interruptions and MAEs during drug rounds before the implementation of the tabard in April 2012 (period 1), as well as 2 weeks and 4 months after tabard implementation (i.e., in May and September 2012, respectively periods 2 and 3). An interruption or a distraction was defined as an event ini- tiated by another professional(s) or something else, and when a nurse interrupted him- or herself. In this study, the term interruption was used for distractions as well as for interruptions. MAEs are defined as a breach of one of the seven rights of medication administration: correct pa- tient, drug, dose, time, route, reason, and documentation (Pape, 2003).

During period 2, nurses’ perspectives regarding the tabard were collected by documenting spontaneous re- marks and asking a single question at the end of the ob- servation: “What is your experience with the drug round tabard?” In period 3, in-depth information on nurses’ perspectives, experiences, and views was collected in a focus group setting to gain insight in barriers and facilita- tors for implementation of the drug round tabards.

Ethical Approval

Ethical approval was not considered necessary by the Institutional Review Board of the Academic Medical

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Center at the University of Amsterdam. This is in accor- dance with the Dutch Medical Ethics Law.

Intervention

Following baseline observation period 1, the inter- vention was introduced during a 5-day implementation week. All nurses working on the participating wards were instructed to wear the tabards while preparing and ad- ministering the medications. Instructions were given by e-mail, posters, and a promotional film. Tabards were flu- orescent yellow with printed text on the back and small text on the chest, reading “Do not disturb, medication round in progress.” After the implementation week, we refrained from instruction on behavior during the drug rounds to determine the unbiased effect of the tabard. Information on the exact observer’s task, documentation frequency, type of interruptions, and MAEs per observed nurse remained blinded.

Observers

All observers (n = 6) were final phase baccalaure- ate nursing students who have followed approximately 2 years of apprenticeship. The observers got instruction on how to score and interpret the items on the obser- vation checklist and also to interfere if they observed MAEs that might be harmful to the patient. Although the students had not graduated yet at the time of the study, we were convinced that they had sufficient knowl- edge and awareness to assess the severity of clinical situations.

Data Collection

Quantitative data were collected on eight different categories of interruptions that are grouped into either verbal or nonverbal interruptions, based on a previ- ously published observation form (Table 1; Smeulers, Hoekstra, van Dijk, Overkamp, & Vermeulen, 2013). To observe the frequency and type of MAEs, we merged it with the “seven right” items of Pape et al. (2003) that we converted into “seven wrongs”: wrong patient, dose, medication, timing, route, indication, and reporting. In a pilot phase, the observers performed eight observations in pairs to validate the checklist. To determine observation agreement on the counting of interruptions and MAEs, the interobserver agreement was calculated using the in- terclass correlation coefficient (ICC). Of the 14 items, 12 items scored an ICC > .80 (almost perfect agreement) and 2 items (i.e., verbal interruptions caused by patients and nonverbal interruptions caused by the surrounding) scored an ICC between .55 and .60 (moderate agreement;

Table 1. Definition of Interruptions During Medication Preparation and Administration

Category Description

Verbal colleague Colleague initiates a dialog with nurse

Verbal person Nurse initiates a dialog

Verbal patient Patient initiates a dialog with nurse

Nonverbal colleague Colleagues initiates an interruption,

e.g., getting supplies in the vicinity

Nonverbal person Nurse initiates interruption, e.g.,

helping a colleague, pager response

Nonverbal patient Patient initiates interruption, e.g.,

being in the vicinity of the nurse

Nonverbal surrounding Surrounding environment, e.g.,

cleaning or stock working staff

Nonverbal logistics Missing supplies for preparing the

medications

Table 2. Focus Group Topics

Topics Subheadings

Drug round tabards and safe

medication administration

Experience positive/negative and

why?

Do you wear the tabard and why?

What additional interventions will

contribute to medication safety?

What do you think of checklists,

visual reminders, and a do not

disturb zone?

Colleagues who do not wear

the tabard

Do you or don’t you confront your

colleagues when they do not

cooperate and why?

Pros and cons regarding

implementation

What factors contribute to your

choice whether to wear or not

to wear the tabard?

What is needed for successful

implementation?

Patients and visitors should be

informed about the purpose

of the tabard

Why should we or shouldn’t we

inform?How should we inform?

Petrie & Sabin, 2009). To solve interobserver variety on the two moderate scored items, they were discussed with the first author. After addressing the disagreements, we considered the observation checklist to be reliable. Obser- vations were performed 7 days per week during six drug rounds per day that occurred at 8 a.m., 12 p.m., 4 p.m., 6 p.m., 8 p.m., and 10 p.m. We randomly selected the nurse to be observed for each drug round, which resulted in a randomly selected patient mix as well.

Focus group participants (n = 9) were selected using purposive sampling based on their expressed attitudes regarding the tabard during observations in period 2 to have a representative mix of positive and negative atti- tudes. Discussion topics were derived from the observa- tions and nurses’ expressions during period 2 (Table 2).

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Table 3. Demographics

Period 1 Period 2 Period 3 Total

n (%) n (%) n (%) n (%)

Observations 105 104 104 313

Gender Male 16 (15) 27 (26) 14 (13) 57 (18)

Female 89 (85) 77 (74) 90 (87) 256 (82)

Age (year) Median (range) 40 (22–64) 42.5 (22–63) 45 (22–62) 42 (22–64)

Education Bachelor’s 41 (39) 46 (45) 53 (51) 140 (45)

Community

college

17 (16) 15 (14) 5 (5) 37 (12)

Inservice 45 (42) 43 (41) 46 (44) 134 (42)

Other 2 (2) 0 0 2 (1)

Observations/ward Neurology 39 (37) 36 (35) 37 (35) 112 (36)

Neurosurgery 35 (33) 40 (38) 33 (32) 108 (34)

Dermatology-

Ophthalmology-

ENT

31 (30) 28 (27) 34 (33) 93 (30)

Medication rounds 8.00 20 (20) 19 (18) 19 (18) 58 (19)

12.00 20 (19) 20 (20) 19 (18) 59 (19)

16.00 22 (21) 20 (20) 26 (25) 68 (21)

18.00 14 (13) 15 (14) 16 (15) 45 (14)

20.00 14 (13) 15 (14) 11 (11) 40 (13)

22.00 15 (14) 15 (14) 13 (13) 43 (14)

The focus group was led by a moderator and an observer. The moderator facilitated an open discussion, which was structured around the derived topics. Special attention was paid to all participants contributing their opinions. The focus group session was taped and transcribed.

Data Entry and Crosscheck

The six observers entered their own data, and they cross-checked each other. One researcher compared all entered data with the original observation.

Sample Size and Data Analysis

Because the effect of tabards on MAEs is unknown, we were unable to calculate the sample size based on this end point; therefore, we used the effects on interruptions. Based on previously published interruption rates of 15% to 50%, we hypothesized an average reduction of 30% for the power calculation (Scott et al., 2010; Smeulers et al., 2013; Trbovich et al., 2010). A sample size of 100 observations before and 100 observations after the inter- vention would have 90% power to detect the effect of the tabards with a .05 significance level.

Descriptive statistics were used to summarize the de- mographics and frequencies of different types of inter- ruptions and MAEs. A Kruskal-Wallis test was performed to compare the interruptions and MAEs due to a skewed distribution of the data. After a natural logarithmic trans- formation, we performed a univariable linear regression

analysis of MAEs (dependent) on interruptions (indepen- dent). All statistical analyses were performed using IBM SPSS statistics version 18.0 (SPSS Inc., Chicago, IL, USA).

Data collected during the observations and the focus group session were analyzed iteratively by four of the six observers. By discussing the interview and focus group items, they coded topics and built a coding tree. Next they grouped the topics and identified the most rele- vant themes related to nurses’ experiences with the drug round tabards regarding barriers and facilitators for im- plementation (Boeije, 2008; Lucassen & Hartman olde, 2007).

Results

A total of 313 medication administrations were ob- served. Distribution of data collection and observations on each ward was distributed evenly on all rounds and for each period, with 40% of the observations occurring during the evening rounds (6 p.m., 8 p.m., and 10 p.m.) and 20% during the weekend rounds. The characteristics of the observed nurses were equally distributed during each period as well (Table 3).

Interruptions

A reduction of 75% of interruptions was found af- ter implementing the drug round tabards (Table 4, Figure 1). The majority of interruptions that were

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Table 4. Interruptions During Medication Administration Rounds

Period 1 Period 2 Period 3

(n = 105) (n = 104) (n = 104) Kruskal-Wallis Number Median (IQR) Number Median (IQR) Number Median (IQR) p

Verbal total 391 3 (4) 297 2 (4) 94 1 (1) <.05

Verbal colleague 168 1 (2) 122 1 (2) 26 0 (0) <.05

Verbal patient 94 0 (1) 71 0 (1) 44 0 (1) .09

Verbal person 130 1 (2) 104 1 (2) 24 0 (0) <.05

Nonverbal total 126 1 (2) 151 1 (2) 15 0 (0) <.05

Nonverbal colleague 15 0 (0) 11 0 (0) 1 0 (0) <.05

Nonverbal patient 4 0 (0) 4 0 (0) 0 NA .13

Nonverbal person 20 0 (0) 24 0 (0) 0 NA <.05

Nonverbal surrounding 94 0 (1) 112 1 (2) 14 0 (0) <.05

Total 517 4 (5) 448 4 (4) 112 1 (2) <.05

Note. IQR interquartile range; NA not applicable.

Figure 1. Mean interruptions per medication administration round.

observed during period 1 were of verbal origin, and most were caused and initiated by colleagues and persons other than patients. The most common nonverbal interruptions were caused by the surroundings (e.g., the telephone, ra- dio, or conversations of others nearby). In period 2, there were fewer interruptions than in period 1. The median total verbal interruptions were reduced over the peri- ods. The median nonverbal interruptions were only re- duced in period 3. A significant effect of the tabards was found for both the verbal and nonverbal interruption rates. The individual interruptions showed a significant decrease, with the exception of verbal and nonverbal in- terruptions initiated by patients. Most decreases in inter- ruptions were seen at the drug rounds occurring at 8 a.m., 12 p.m., and 6 p.m. For the drug rounds at 8 p.m. and 10 p.m., we observed a slight increase in interruptions in period 2, although in period 3 a further decrease occurred (see Figure 1).

Medication Administration Errors

A 66%, and significant, reduction in MAEs was found after implementing the tabards (Table 5, Figure 2). The most frequent procedural MAEs are the absence of patient identification, incorrect administration time (ei- ther too early or too late), and not reporting in accor- dance with standard procedures. Individual MAEs that did not decrease significantly were administering the wrong medication, administration through the wrong route, and administration for an incorrect indication. De- creased MAEs were mainly found in the drug rounds at 8 a.m., 8 p.m., and 10 p.m. (see Figure 2).

Regression Model

The univariable linear regression model revealed in- terruptions as a significant predictor for MAEs (p < .05;

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Table 5. Medication Administration Errors During Medication Administration Rounds

Period 1 Period 2 Period 3

(n = 105) (n = 104) (n = 104) Kruskal-Wallis Number Median (IQR) Number Median (IQR) Number Median (IQR) p

Wrong patient 194 2 (2) 183 2 (2) 119 1 (1) <.05

Wrong dose 16 0 (0) 9 0 (0) 0 NA <.05

Wrong medication 7 0 (0) 6 0 (0) 0 NA .08

Wrong timing 91 0 (1) 64 0 (1) 1 0 (0) <.05

Wrong route 4 0 (0) 4 0 (0) 0 NA .13

Wrong indication 0 NA 1 0 (0) 0 NA .37

Wrong reporting 126 1 (2) 82 0 (1) 0 NA <.05

Total 432 3 (3) 349 2.5 (3) 120 1 (1) <.05

Note. IQR interquartile range; NA not applicable.

Figure 2. Mean MAEs per medication administration round.

Table 6. Parameter Estimate for Intercept Medication Administration Errors and Variable Interruptions

Parameter Standard Test

Variable estimate (B) error statistic p

Intercept .800 .065 12.361 <.05

Interruptions .271 .045 6.005 <.05

Table 6). The R2 of the model is 10.4%, which indicates that approximately one tenth of the MAEs can be ex- plained by interruptions.

Nurses’ Experiences With Wearing the Tabard

By documenting remarks during the drug rounds and asking a single interview question at the end of drug rounds, we collected nurses’ experiences with and opin- ions about wearing the tabards. The reactions ranged from positive and enthusiastic to negative and even re- fusal to wear the tabard. Experiences with wearing the drug round tabards were related to three main topics: per-

sonal considerations, patient perceptions, and considera- tions regarding the effectiveness of the tabards.

Personal considerations. Frequently mentioned personal considerations include the nurses’ perception of their appearances while wearing the tabards: “I definitely won’t wear the tabard, it is ridiculous! . . . I am in for any kind of intervention and improvement, but in this tabard, I stand just like an idiot.” The nurses also mentioned hy- gienic issues as a personal barrier to wearing the tabard: “I purposively do not wear the tabard because I think it is filthy. Everybody wears it, contaminating it with sweat or spilling dirt or things on it.”

Patient perceptions. Nurses have concerns about the way in which patients and visitors might perceive the tabard. These remarks sometimes represented the nurses’ opinion that the tabard led the patients to con- sider the staff to be unapproachable: “I think the tabard gives an unfriendly signal to the patient. When patients have questions or need any kind of assistant or care, they

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should not need to hesitate in asking their nurse.” The nurses sometimes expressed feelings about the opposite effect:

The intention of the tabard is good; it gives a clear signal that you need to concentrate on the medication task. However, the tabard looks quite outstanding, and because of this, it attracts patients’ and visitors’ attention, and this results in questions about the reason for wearing the tabard, which distracts eventually from your medication task. But overall, they are an excellent idea.

Effectiveness considerations. Perspectives on the effectiveness of the tabard varied. Some felt that it did not work at all: “I think it is nonsense and don’t think it is effective.” Other nurses mentioned that the tabard was only useful at certain times:

It is a very good idea, especially during daytime. It will make people think about “do not disturb,” but I think that during evening shifts it is more efficacious, that is the time when there are many visitors. I really think it is a good idea!

The intervention works as a signal for colleagues, they realise that you are doing medication. However, I do not think the tabard is effective in an evening shift when there are many visitors, no secretary to answer telephone calls etc.

Six of the nine invited nurses were able to attend and participate in the focus group discussion. They discussed the prominent color of the tabard as a barrier for use as some patients complained about the fluorescent yel- low color. The participants suggested another color might solve this. Hygiene issues were not considered a problem for exchanging the tabard among nurses; nevertheless, the participants found it important to establish a cleaning protocol for the tabards with the hospital laundry service. All participants frequently were asked questions about the purpose of the tabards from visitors and patients. These questions distracted them from their tasks. There- fore, they suggested informing patients and visitors about the tabard upon admission or entry to the hospital. In ad- dition to the drug round tabards, they expressed thoughts about the importance of focusing on team culture, where it is considered normal to not disturb each other during tasks and where it is acceptable to address disturbances when they do occur. The group also discussed the impor- tance of leadership and team member role models as they considered this to be an important stimulus and good mo- tivation for nurses to wear the tabard.

Discussion

This study shows a significant effect of drug round tabards on interruptions and MAE rate and a significant linearity between interruptions and MAEs (R2 of 10.4%). Therefore, we can conclude that the tabards were effec- tive in improving medication administration safety. How- ever, from the nurses’ experiences it became clear that they have mixed emotions about wearing the tabard. Nurses feel awkward and uncomfortable in the tabard, but they are prepared to wear the tabard if its effective- ness can be demonstrated, as also found by Scott et al. (2010). In the focus group, suggestions were made to change the color and appearance of the tabard. When asked about the effectiveness of the tabard, some nurses had positive experiences, but others expressed doubts about its effectiveness. Patients are not always aware of the tabard’s purpose, and wearing a tabard did not change the patients’ attempts to attract the nurses’ attention. This was confirmed by the quantitative outcomes that showed a nonsignificant effect of the tabard on interrup- tions caused by patients. The nurses also expressed their opinion that patients should always feel free to ask the nurses questions. Additionally, the nurses reported that the main sources of interruptions during drug rounds are colleagues and not patients. Another important item to consider is hygiene; some nurses complained that the tabards are worn by multiple nurses and are not personal items. The focus group suggested a cleaning protocol to address the hygiene issue. In their study concerning the infection risk of tabards, Scott et al. (2010) indicated that all tested swabs were negative for methicillin-resistant Staphylococcus aureus but had a positive general culture. We suggest a well-defined hygiene protocol when imple- menting the drug round tabard in a hospital.

Our results of the regression model show a significant linearity, but the magnitude of the contribution of in- terruptions on MAEs seems small. This does not support the result found in other studies, which indicate a greater effect of interruptions on MAEs (Biron et al., 2009; Scott- Cawiezell et al., 2007; Westbrook et al., 2010). In con- trast, another study showed the results of implement- ing a multi-intervention program, including tabards, in which the number of interruptions by staff increased sig- nificantly (Tomietto, Sartor, Mazzocoli, & Palese, 2012). This indicates that there are more factors than the tabard alone that influence the resulting effect. Given the liter- ature, we hypothesize that paying attention to the pro- cess made nurses more aware of their tasks in medication administration, possibly leading to increased concentra- tion and dedication (Paquet, Courcy, Lavoie-Tremblay, Gagnon, & Maillet, 2012). Another possible contribut- ing factor was more involvement of the ward managers

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during drug rounds. They were eager to reduce MAEs and wanted to contribute to the study. These factors may have caused nurses to realize the importance of their task. Because previously published studies have sug- gested that nurses should change their behavior to reduce interruptions and MAEs, the drug round tabard can be considered a tool for changing nurses’ behavior (Biron et al., 2009; Relihan, O’Brien, O’Hara, & Silke, 2010). In conclusion, the drug round tabards created an ob- served effect on MAEs that was most likely not only the result of the tabards. This explains the significant results on both MAEs and interruptions and the low regression model R2.

To obtain representative results, we observed all drug rounds, with the exception of night shifts, on both surgi- cal and internal medicine wards. The mixed method ap- proach with a combination of quantitative data collection on the effect of the tabards with experiences and per- spectives of the participants in a mixed methods design proved a valuable research design because it uncovered all incentives (Glasziou et al., 2011; Seidl & Newhouse, 2012). The combined checklist was validated during this study using a nested interobserver agreement test (ICC) where 2 of the 14 observation items scored moderate agreement among observers, which could be considered a weakness for the observation process. However, 12 items scored almost perfect agreement, and after discussing the interpretation of the two moderate scored items, we con- sidered the checklist reliable. Furthermore, this study has some limitations. Although some form of observer effect could not be eliminated in our study, we assume that this hardly influenced the effects since Barker, Flynn, and Pepper (2002) stated that observations are a valid, effi- cient, and accurate method of detecting MAEs and that there is no significant effect of observers on the observed personnel. Secondly, all observers were final phase nurs- ing students, and one can argue their ability to observe the complex task of medication preparation and admin- istration. However, they are trained and experienced in medication management, and since they have no rela- tionship with the team under observation, they are able to get unbiased information and observations. Lastly, in a before-after design, one cannot correct for changes over time. Although we carefully selected the observa- tion periods, we could not prevent the influence of low bed occupancy on all three observed wards during the different observation periods. In future research, one could consider more robust study designs to address this issue (e.g., a cluster randomized controlled trial or a con- trolled before-after study; Raban & Westbrook, 2013). In contrast to previous studies on multifaceted strategies, we would recommend analyzing the single contribution of each intervention to avoid the implementation of unnec-

essary and non-evidence-based interventions (Freeman et al., 2012; Relihan et al., 2010; Tomietto et al., 2012).

Conclusions and Implications for Further Research

Acknowledgments

We would like to thank Mirthe van Loon, Manon Boers, Nousjka Westerlaken, Heleen van Essen, Milou Bakker, Lisa Appelman, Andrea Kuckert, and Marjoke Hoekstra for their contributions to our study.

Clinical Resources

Medication safety: � World Health Organization, Action on Pa-

tient Safety - High 5s: http://www.who.int/ patientsafety/implementation/solutions/high5s/en/

� Institute for Safe Medication Practices, Medications Safety Tools & Resources: http://www.ismp.org/

� ECRI Institute, Patient Safety, Risk, and Qual- ity Assessment Services: https://www.ecri.org/ Products/PatientSafetyQualityRiskManagement/ Pages/Assessment-Services.aspx

� The National Coordinating Council for Med- ication Error Reporting and Prevention: http://www.nccmerp.org/

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