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Patient Safety Tip of the Week 

June 22, 2021

Remotely Monitoring Suicidal Patients in Non-Behavioral Health Areas

One problematic area for hospitals is safely managing potentially suicidal patients who must be housed in non-behavioral health areas of the hospital, such as the emergency department or a med/surg floor. We’ve done multiple columns on in-hospital suicides (see list below). When patients at risk for suicide or self-harm, elopement, or even jumping from windows are housed in such areas, we typically put them on 1:1 continuous observation. But that is expensive, and we often have a lack of appropriately trained “sitters” to monitor such patients in these areas. And there are many incidents in which an adverse event took place despite the presence of a “sitter”.

Researchers at the Brigham and Women’s Hospital in Boston (Kroll 2020) assessed the feasibility of using continuous virtual monitoring in such situations. Kroll and colleagues note multiple reasons that make continuous monitoring of such patients difficult:

• The “sitter” or “observer” is most often a non-licensed staff member
• No widespread guidelines exist to direct how precisely continuous observation should be provided
• Continuous observation policies vary widely between institutions
• Even within institutions continuous observation may be carried out in an inconsistent manner
• The job of observing patients is tedious
• Observers often become distracted or engage with patients in ways other than simply watching them
• Patients who undergo continuous observation may experience such interactions either positively or negatively

So, they piloted continuous virtual monitoring as a method of patient observation in which an observer provides continuous observation to one or more patients at once from a central location with the assistance of high-definition live stream video surveillance technology. Their setup of the unit includes a 360-degree view of the clinical area, continuous monitoring by a staff member, and linkage to immediate intervention by staff if called for. Because this was a new concept, the implementation team sought to identify patients who had a lower risk of impulsivity for assignment to virtual monitoring. They also excluded patients with psychosis, patients at risk for elopement, those with a prior history of attempted suicide or self-harm in hospital, and several other exclusionary criteria. The decision to include individual patients in the virtual monitoring program was made by consulting psychiatrists and nurses together.

A monitoring technician (MT) received a live video stream from a panel of 1-10 patients. The MT had flexibility to reduce the maximum number of monitored patients if they felt the panel was sufficiently acute so that it would be difficult to accommodate new patients.

The MT was housed in a dedicated room with the monitoring equipment. He/she could communicate with patients directly through a speaker box attached to the device and could call the patient's nurse on a cell phone associated with the mobile device if he/she noticed concerning behavior or environmental hazards. He/she could also activate a “stat alarm” if there was no response to urgent phone calls, or there was rapidly escalating behavior, or there was loss of visualizing the patient.

Nurse educators trained nurses on inpatient medical units in the protocol for monitoring patients on suicide precautions, including the option to use virtual monitoring. The MT’s also received this training.

The pilot project included 39 patients, 27 (69%) on hospital floors and 12 (31%) in the ED. No adverse behavioral events were reported among this group of patients. In 4 patients the virtual monitoring was discontinued because the patient could not be redirected by the MT or exhibited new signs or symptoms to indicate a higher impulsivity risk, requiring a shift to 1:1 in-room continuous observation. In the others, virtual monitoring was terminated upon discharge, transfer, or discontinuation of suicide precautions.

The researchers did report a number of incidents in at-risk patients who were not on the pilot protocol, but we consider any such comparison inappropriate because of the strict selection criteria.

The maximum number of patients receiving virtual monitoring for an indication of suicide precautions at a single time was 3 but the average daily census for the MT’s was 6.2 patients (they were also apparently performing virtual monitoring for other indications on all hospital and ED units).

The authors conclude their pilot demonstrates that virtual monitoring can feasibly be used to monitor suicide risk in patients who are carefully screened for impulsivity.

Because general hospitals are bound to deal with patients at risk for suicide or self-harm regardless of whether they have a behavioral health unit, it is incumbent upon such hospitals to plan for safe care of such patients when they are in the ED or non-behavioral health inpatient units.

Our February 2, 2021 Patient Safety Tip of the Week “MGH Protocols Reduce Risk of Self-Harm in ED” described a program the Massachusetts General Hospital put in place to reduce self-harm in ED patients (Donovan 2021). You should go to that column for details.

In addition to adequately training any personnel you might use as “sitters” or “observers” for at-risk patients, there are a number of other important considerations for all such hospitals. We recommend that such hospitals might dedicate one or more rooms specifically for such patients. That means they should meet all the requirements in the the VA Mental Health Environment of Care Checklist (MHEOCC), which looks at issues such as loopable fixtures. You might even consider installing in those rooms windows that are resistant to patient attempts to jump from them.

Particular attention needs to be paid to use of bathroom facilities (see our August 29, 2017 Patient Safety Tip of the Week “Suicide in the Bathroom”). That means not only ensuring there are no loopable fixtures or other dangerous items in the bathrooms, but also ensuring that a reasonable balance be achieved between patient privacy and adequate monitoring/observation while the patient is in the bathroom.

Since these patients are usually not on a behavioral health unit because they have a medical or surgical condition, you must anticipate they may at some point require transport to other areas of the hospital, such as the radiology suite or the OR. Such transports can be very vulnerable periods. Patients may abscond during transports or they might go into a bathroom (or other room) that has features which could be used for suicide or self-harm. Therefore, it is essential that your “Ticket to Ride” intrahospital transport checklist include some provision for suicide or elopement risk and all staff accompanying the patient during the transport (as well as those who might take responsibility for the patient in the destination site) are adequately trained to deal with such patients.

The Kroll study suggests that there may well be a low-risk group of patients for whom continuous virtual monitoring may be useful, safe, and cost-effective. But you need to have strict patient selection criteria for such programs. You also need to have in place a more comprehensive program to deal with patients at higher risk for suicide, self-harm, jumping, or elopement.

Some of our prior columns on preventing hospital suicides:

• January 6, 2009 “Preventing Inpatient Suicides”
• February 9, 2010 “More on Preventing Inpatient Suicides”
• March 16, 2010 “A Patient Safety Scavenger Hunt”
• December 2010 “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”
• September 27, 2011 “The Canadian Suicide Risk Assessment Guide”
• December 2011 “Columbia Suicide Severity Rating Scale”
• July 2012 “VA Checklist Reduces Suicide Risk”
• August 2013 “Suicide Attempts on Med/Surg Units”
• August 25, 2015 “Checklist for Intrahospital Transport”
• October 6, 2015 “Suicide and Other Violent Inpatient Deaths”
• March 2016 “TJC Sentinel Event Alert on Preventing Suicide”
• April 12, 2016 “Falls from Hospital Windows”
• February 14, 2017 “Yet More Jumps from Hospital Windows”
• August 29, 2017 “Suicide in the Bathroom”
• December 12, 2017 “Joint Commission on Suicide Prevention”
• July 10, 2018 “Another Jump from a Hospital Window”
• September 18, 2018 “More on Hospital Suicides”
• January 22, 2019 “Wandering Patients”
• January 29, 2019 “National Patient Safety Goal for Suicide Prevention”
• July 30, 2019 “Lessons from Hospital Suicide Attempts”
• September 3, 2019 “Lessons from an Inpatient Suicide”
• August 11, 2020 “Above-Door Alarms to Prevent Suicides”
• September 22, 2020 “VA RCA’s: Suicide Risks Vary by Site”
• February 2, 2021 “MGH Protocols Reduce Risk of Self-Harm in ED”

Some of our past columns on DVT risk in behavioral health settings:

• October 2010 “Antipsychotic Drugs and Venous Thrombembolism”
• May 10, 2016 “Medical Problems in Behavioral Heatlth”
• February 6, 2018 “Adverse Events in Inpatient Psychiatry”
• February 2020 “DVT and Behavioral Health”

Some of our past columns on issues related to behavioral health:

• January 6, 2009 “Preventing Inpatient Suicides”
• September 22, 2009 “Psychotropic Drugs and Falls in the SNF”
• February 9, 2010 “More on Preventing Inpatient Suicides”
• March 16, 2010 “A Patient Safety Scavenger Hunt”
• October 2010 “Antipsychotic Drugs and Venous Thrombembolism”
• December 2010 “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”
• September 27, 2011 “The Canadian Suicide Risk Assessment Guide”
• December 2011 “Columbia Suicide Severity Rating Scale”
• July 2012 “VA Checklist Reduces Suicide Risk”
• August 2013 “Suicide Attempts on Med/Surg Units”
• January 15, 2013 “Falls on Inpatient Psychiatry”
• April 2, 2013 “Absconding from Behavioral Health Services”
• August 25, 2015 “Checklist for Intrahospital Transport”
• October 6, 2015 “Suicide and Other Violent Inpatient Deaths”
• March 2016 “TJC Sentinel Event Alert on Preventing Suicide”
• April 12, 2016 “Falls from Hospital Windows”
• May 10, 2016 “Medical Problems in Behavioral Heatlth”
• February 14, 2017 “Yet More Jumps from Hospital Windows”
• March 14, 2017 “More on Falls on Inpatient Psychiatry”
• August 29, 2017 “Suicide in the Bathroom”
• December 12, 2017 “Joint Commission on Suicide Prevention”
• February 6, 2018 “Adverse Events in Inpatient Psychiatry”
• July 10, 2018 “Another Jump from a Hospital Window”
• September 18, 2018 “More on Hospital Suicides”
• January 22, 2019 “Wandering Patients”
• January 29, 2019 “National Patient Safety Goal for Suicide Prevention”
• July 30, 2019 “Lessons from Hospital Suicide Attempts”
• September 3, 2019 “Lessons from an Inpatient Suicide”
• February 2020 “DVT and Behavioral Health”
• March 2020 “Risk Factor for Preventable Harm: Psychiatric Diagnosis”
• August 11, 2020 “Above-Door Alarms to Prevent Suicides”
• September 22, 2020 “VA RCA’s: Suicide Risks Vary by Site”
• February 2, 2021 “MGH Protocols Reduce Risk of Self-Harm in ED”

References:

Kroll DS, Stanghellini E, DesRoches SL, et al. Virtual monitoring of suicide risk in the general hospital and emergency department. General Hospital Psychiatry 2020; 63: 33-38

https://www.sciencedirect.com/science/article/abs/pii/S0163834318302226

Donovan AL, Aaronson EL, Black L, et al. Keeping Patients at Risk for Self-Harm Safe in the Emergency Department: A Protocolized Approach. Joint Commission Journal on Quality and Patient Safety 2021; 47(1): 23-30

https://www.jointcommissionjournal.com/article/S1553-7250(20)30215-4/fulltext

Mental Health Environment of Care Checklist (VA)

http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx

video

http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp

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What's New in the Patient Safety World?

June 2021

·ISMP on Patch-Related Issues

·Does Nurse-to-Patient Ratio Legislation Help?

·No More Lead Aprons for Patients?

·Sleep Hygiene Program Improves Sleep Quality for Hospitalized Patients

ISMP on Patch-Related Issues

Transdermal medication patches are an effective way to administer certain medications under appropriate circumstances. But there are also dangers associated with their use. We’ve noted that discarded patches may still contain active drug and children and pets may be exposed to them. We’ve also noted how a second patch may be applied to a patient’s skin, not recognizing the presence of another patch, resulting in an overdose for the patient. And we’ve also noted that patches containing metal or ferromagnetic components may overheat during MRI scanning, resulting in burns. Most of our columns have dealt with opioid patches, particularly Fentanyl, but problems may occur with virtually any transdermal patch.

ISMP (Institute for Safe Medication Practices) recently reported on more than 50 reports associated with 12 different transdermal medication patches submitted to the ISMP MERP within the past 4 years (ISMP 2021). Patches most frequently involved in reported errors included fentaNYL (n = 16), cloNIDine (n = 10), scopolamine (n = 7), and estradiol (n = 6). ISMP categorized the problems in the following areas:

• Errors in the Frequency of Patch Application or Removal
• Lack of Awareness of Patches on the Patient’s Skin
• Dose Confusion Due to Labeling
• Inappropriate Patch Prescribing
• Wrong Dose Dispensing Errors
• Patch Cover Applied without the Medication Patch
• Wrong Patch Prescribed Due to Similar Ingredients
• Miscellaneous Errors

ISMP reiterated the problem of failing to identify patches on the patient’s skin, not removing an old patch when applying a new patch, and/or finding multiple patches on patients that had been left on longer than prescribed. Hospital admission may be a time of vulnerability to the first failure, since a patch applied prior to admission might be easily overlooked. Failure to recognize prior patches or presence of multiple patches on the skin of some patients may be more likely with those patches that are clear or beige.

Inappropriate patch prescribing applied most often to fentaNYL patches. Our multiple columns on long-acting opioids have stressed that these are intended for opioid-tolerant patients and should not be prescribed for acute pain or in opioid-naïve patients.

We encourage you to read ISMP’s full article. It provides examples in each of the above categories and provides very important recommendations for all patches and for specific patch types.

Our prior articles pertaining to long-acting and/or extended release preparations of opioids:

• April 2010                   “RCA: Epidural Solution Infused Intravenously”
• July 13, 2010              “Postoperative Opioid-Induced Respiratory Depression”
• January 18, 2011         “More on Medication Errors in Long Term Care”
• April 12, 2011             “Medication Issues in the Ambulatory Setting”
• June 28, 2011              “Long-Acting and Extended-Release Opioid Dangers”
• September 13, 2011    “Do You Use Fentanyl Transdermal Patches Safely?”
• November 8, 2011      “WHO’s Multi-Professional Patient Safety Curriculum Guide”
• May 2012                    “Another Fentanyl Patch Warning from FDA”
• July 24, 2012              “FDA and Extended-Release/Long-Acting Opioids”
• September 2012          “Joint Commission Sentinel Event Alert on Opioids”
• March 2013                 “Try Googling Fentanyl Accidents”
• September 2013          “ISMP Outreach on Fentanyl Patch Safety”
• October 2013              “Opioid Safety Actions and Resources”
• February 24, 2015       “More Risks with Long-Acting Opioids”
• February 2017             “FDA Approves Even More Long-Acting Opioids”
• February 12, 2019       “2 ER Drug Studies: Reassurances and Reservations”
• February 2020             “The FDA and Long-Acting Opioids”
• August 2020               “Fentanyl Patches in the Crosshairs Again”

Our prior columns on iatrogenic burns:

• March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
• June 1, 2010 “Iatrogenic Burns”
• October 5, 2010 “More Iatrogenic Burns”
• December 23, 2014 “Iatrogenic Burns in the News Again”
• March 2015 “Another Source of Iatrogenic Burns”
• September 5, 2017 “Another Iatrogenic Burn”
• June 5, 2018 “Pennsylvania Patient Safety Authority on Iatrogenic Burns”
• July 28, 2020 “Electrosurgical Safety”
• January 2021 “New MRI Risk: Face Masks”

References:

ISMP (Institute for Safe Medication Practices). Analysis of Transdermal Medication Patch Errors Uncovers a “Patchwork” of Safety Challenges. ISMP Medication Safety Alert! Acute Care Edition 2021; 26(5): March 11, 2021

https://www.ismp.org/resources/analysis-transdermal-medication-patch-errors-uncovers-patchwork-safety-challenges

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Does Nurse-to-Patient Ratio Legislation Help?

We’ve done multiple columns discussing how better nursing staffing leads to better patient outcomes and improved patient safety. We’ve stressed the importance of nurse workload rather than staffing levels per se. But most attempts to improve nurse staffing have focused on nurse-to-patient ratios. What is the evidence that just mandating a minimum nurse-to-patient ratio improves outcomes? One of the problems is that all prior studies have been before-and-after evaluations and none were prospective.

A recent study from Queensland, Australia appears to answer that. McHugh et al. (McHugh 2021) were able to prospectively compare patient outcomes at 27 hospitals subject to minimum nurse-to-patient ratios (the “intervention” hospitals) with 28 hospitals that were not (the “comparison” hospitals).

After implementation, mortality rates were not significantly higher than at baseline in comparison hospitals (adjusted odds ratio 1.07) but were significantly lower than at baseline in intervention hospitals (aOR 0.89). From baseline to post-implementation, readmissions increased in comparison hospitals (1.06), but not in intervention hospitals (1.00). Length of stay (LOS) decreased in both groups post-implementation, but the reduction was more pronounced in intervention hospitals than in comparison hospitals. Staffing improvements by one patient per nurse produced reductions in mortality (OR 0.93), readmissions (0.93), and LOS (adjusted incident rate ratio 0.97).

And here’s the key point for administrators and policy makers: in addition to producing better outcomes, the costs avoided due to fewer readmissions and shorter LOS were more than twice the cost of the additional nurse staffing. We always add a point of caution when using formulas to impute cost savings from fewer admissions and shortened length of stay – those savings would come from actually reducing personnel costs. Those hospitals that can benefit the most from such reductions are those that can close a whole nursing unit. Lesser reductions are more difficult to achieve. We also reiterate our position that some flexibility is needed. Rather than just focusing on the nurse-to-patient ratio, we need to match nurse workload to patient load. But improving the nurse-to-patient ratio is a good first step.

We hope that the naysayers to mandated minimum nurse-to-patient ratios who say such mandates would be too costly will look at the results from Queensland and reassess their opposition to such mandates.

As pointed out in the editorial accompanying the McHugh study (Ullman 2021), the current and likely near-future shortage of nurses makes improving nurse-to-patient ratios challenging. Ullman calls for robust efforts to boost the nursing workforce.

Some of our other columns on nursing workload and missed nursing care/care left undone:

November 26, 2013    “Missed Care: New Opportunities?”

May 9, 2017                “Missed Nursing Care and Mortality Risk”

March 6, 2018             “Nurse Workload and Mortality”

May 29, 2018              “More on Nursing Workload and Patient Safety”

October 2018               “Nurse Staffing Legislative Efforts”

February 2019             “Nurse Staffing, Workload, Missed Care, Mortality”

July 2019                    “HAI’s and Nurse Staffing”

September 1, 2020      “NY State and Nurse Staffing Issues”

February 9, 2021         “Nursing Burnout”

References:

McHugh MD, Aiken LH, Sloane DM, et al. Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. The Lancet 2021; Published: May 11, 2021

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00768-6/fulltext

Ullman AJ, Davidson PM. Patient safety: the value of the nurse. The Lancet 2021; Published: May 11, 2021

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00981-8/fulltext

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No More Lead Aprons for Patients?

The time-honored procedure of shielding patients’ gonads from radiation with lead aprons during diagnostic radiology exams has come to an end. In January 2021 both the American College of Radiology (ACR 2021) and the National Council on Radiation Protection and Measurement (NCRP 2021) announced that routine gonadal shielding during abdominal and pelvic radiography is no longer recommended.

Gonadal shielding has been used since the 1950’s with the rationale that it prevented radiation damage to reproductive organs and consequent heritable genetic defects. The NCRP statement notes that the risks of heritable genetic effects are now considered to be much less than previously estimated and that improvements in technology since the 1950’s have resulted in up to a 95 % reduction in the absorbed dose to pelvic organs from radiography.

It also notes that gonadal shielding can interfere with the use of automatic exposure control, thereby causing an increase in dose to other pelvic and abdominal organs that may be more radiosensitive. It also may not completely shield the gonads in the majority of patients due to the limited area of the shield and the normal variations in patient anatomy. Moreover, a substantial portion of gonadal dose to the ovaries is delivered by scattered x rays that are not attenuated by gonadal shielding.

Gonadal shielding also obscures portions of pelvic anatomy and may obscure important findings on radiographs, limiting the practical dimensions and area of the shield.

Thus, NCRP concludes that in most circumstances gonadal shielding use does not contribute significantly to reducing risks from exposure and may have the unintended consequences of increased exposure and loss of valuable diagnostic information. Therefore, use of gonadal shielding is not justified as a routine part of radiological protection.

NCRP notes that gonadal shielding may be used for circumstances where a patient, parent or caregiver requests that gonadal shielding be used. It recommends such requests for use of gonadal shielding should be discussed to facilitate informed and mutual decision making. Information should be provided that will help to answer the patient’s questions and understand the risks and benefits. Gonadal shielding may be permissible when it will not interfere with the purpose of the examination. If consent for the examination cannot be obtained without its use, gonadal shielding use should adhere to institutional or practice guidelines or policies that minimize or eliminate the negative impact on diagnostic potential.

Acknowledging that many will question this move away from such a time-honored practice, NCRP also issued a companion statement “Implementation Guidance for Ending Routine Gonadal Shielding During Abdominal and Pelvic Radiography”.

References:

ACR (American College of Radiology). NCRP Recommends Against Routine Gonadal Shielding. American College of Radiology 2021; January 13, 2021

https://www.acr.org/Media-Center/ACR-News-Releases/2021/NCRP-Recommends-Against-Routine-Gonadal-Shielding

NCRP (National Council on Radiation Protection and Measurement). NCRP Recommendations for Ending Routine Gonadal Shielding During Abdominal and Pelvic Radiography. NCRP Statement No. 13, January 12, 2021

https://ncrponline.org/wp-content/themes/ncrp/PDFs/Statement13.pdf

NCRP (National Council on Radiation Protection and Measurement). Implementation Guidance for Ending Routine Gonadal Shielding During Abdominal and Pelvic Radiography. Companion to NCRP Statement No. 13, January 12, 202

https://ncrponline.org/wp-content/themes/ncrp/PDFs/Stat13_Companion_Comm.pdf

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Sleep Hygiene Program Improves Sleep Quality for Hospitalized Patients

Our August 6, 2013 Patient Safety Tip of the Week “Let Me Sleep!” highlighted the problem of sleep deprivation amongst hospitalized inpatients. Interference with sleep is also a contributing factor to other problems, such as delirium. For years we’ve espoused the “Say no to sleep meds” approach to hospitalized patients. That means identifying the numerous things we do that prevent patients from getting needed sleep and using nonpharmacological approaches to improve their sleep while hospitalized.

Herscher et al. (Herscher 2021) recently reported on successful implementation of a nonpharmacologic sleep hygiene intervention to improve sleep quality in hospitalized patients. The intervention consisted of a bundle with the following components:

• A short script with sleep hygiene prompts, such as whether patients would like the shades closed or the lights turned off
• A sleep package including an eye mask, earplugs, lavender scent pad, and non-caffeinated tea
• Relaxing music was played at bedtime
• Signs promoting the importance of quietness at night were placed around the unit

Their program also included provider education and use of front-line “champions”.

Patients’ sleep was measured by the Richards-Campbell Sleep Questionnaire (RCSQ). 931 patients received the intervention. A sample of surveyed patients showed an increase in the RCSQ global score from 6.0 to 6.2 from the pre- to post- intervention periods (p = 0.041), plus increases in three of the five individual survey components. In addition, there was an improvement in the HCAHPS “quietness at night” score, from 34.1% pre-intervention to 42.5% post-intervention.

Those results are modest and we don’t know if they are sustainable or generalizable, but it is a step in the right direction.

We recommend you go back to our Patient Safety Tips of the Week for November 6, 2018 “More on Promoting Sleep in Inpatients” and March 16, 2021 “Sleep Program Successfully Reduces Delirium” and our August 2019 What's New in the Patient Safety World column “Tools for Reducing Sleep Meds in Hospitals” for more nonpharmacologic interventions to promote healthier sleep in hospitalized inpatients.

Some of our previous columns on safety issues associated with sleep meds and promoting sleep in inpatients:

August 2009               “Bold Experiment: Hospitals Saying No to Sleep Meds”

March 23, 2010           “ISMP Guidelines for Standard Order Sets”

May 2012                    “Safety of Hypnotic Drugs”

November 2012          “More on Safety of Sleep Meds”

March 2013                 “Sedative/Hypnotics and Falls”

June 2013                    “Zolpidem and Emergency Room Visits”

August 6, 2013           “Let Me Sleep!”

June 3, 2014                 “More on the Risk of Sedative/Hypnotics”

May 15, 2018              “Helping Inpatients Sleep”

June 2018                    “Deprescribing Benzodiazepine Receptor Agonists”

November 6, 2018      “More on Promoting Sleep in Inpatients”

June 2019                    “FDA Boxed Warning on Sleep Meds”

August 2019               “Tools for Reducing Sleep Meds in Hospitals”

March 16, 2021           “Sleep Program Successfully Reduces Delirium”

References:

Herscher M, Mikhaylov D, Barazani S, et al. A Sleep Hygiene Intervention to Improve Sleep Quality for Hospitalized Patients. The Joint Commission Journal on Quality and Patient Safety 2021; 47(6): 343-346. Published: February 10, 2021

https://www.jointcommissionjournal.com/article/S1553-7250(21)00032-5/fulltext

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