key: cord-024120-3eemj37r
authors: Schiff, Gordon D.; Graber, Mark L.
title: An Interview with Gordon D. Schiff
date: 2020-04-29
journal: Jt Comm J Qual Patient Saf
DOI: 10.1016/j.jcjq.2020.04.008
sha: 
doc_id: 24120
cord_uid: 3eemj37r

nan

Just as it drove John Eisenberg, a '60s activist vision propelled our generation of medical students to do our residencies at public hospitals, including Cook County Hospital, Chicago's large public hospital serving predominantly uninsured, poorer, African American patients from Chicago's west and south sides (where I grew up). It was there that it became obvious to me that our struggle to provide access and quality for our patients was about the need to improve systems-there was clearly no point in blaming dedicated staff, doing their best in an under-resourced setting, for all the quality shortfalls.

In addition, it was clear that medication prescribing could and should be considerably safer. It was a time when there was liberal prescribing of drugs such as benzodiazepines (to treat everyday anxiety, relax muscles, or deal with ulcers or MI stresses) and estrogens (the number one drug prescribed to women, promoted as helping women prevent cancer and MIs and remain "feminine forever"), and widespread use of potent cardiac antiarrhythmic drugs (which had serious adverse effects but minimal evidence to support their efficacy, and were found to actually increase mortality). [3] [4] [5] [6] It led us, as medical students and later as residents and attendings, to question the overpromotion, overuse, and safety of such prescriptions and seek ways to make prescribing safer. The Joint Commission recognized this safety need and mandated that each hospital review their use of medications with an eye to safer prescribing. Cook County Hospital set up a Drug Utilization Review Committee, and I became its first chair. We examined prescribing patterns by downloading data from the Cook County pharmacy's comprehensive dispensing database (since County's indigent patients obtained virtually all of their medications for free from the Hospital's outpatient pharmacy, this provided a comprehensive look at their drug prescriptions) and found many improvement opportunities. We also linked lab data (manually at first; later electronically) to the pharmacy data; one finding was that more than half of the theophylline-toxic patients continued to receive IV infusions more than 10 hours after the toxic sample was drawn, and many patients were experiencing GI, neuro-psychiatric, and cardiac symptoms that were not recognized as being caused by theophylline toxicity. 7 

Most readers are familiar with Donabedian's triad of structure, process, and outcomes, but I'd say I was influenced by the Donabedian-led triad: Avedis Donabedian, Lucian Leape, and Don Berwick. I have had the privilege to personally learn from each of them, and all three demonstrate the veracity of what I refer to as Schiff's paradox: the bigger and busier they are, the more time they will take to extend a hand to support a little guy like me, especially when I was just learning about quality and safety. To walk in their footsteps in receiving this award is an enormous, humbling honor.

Of your many patient safety endeavors, which ones have given you the greatest pride? Which ones will have the highest impact on patient safety? What are your current projects?

We do have a current diagnostic error learning network project called PRIDE (Primary Care Improving in Diagnostic Error). 8 So I guess you can say that project is an important source of pride! But seriously, this project (funded by the Moore Foundation), like several others, is a source of satisfaction because we are bringing together a broad multidisciplinary team of practitioners and stakeholders (especially non-MDs) to increase our understanding of diagnostic errors, their causes, and ways they can be prevented.

Of the 93 initial AHRQ patient safety grants awarded in the early 2000s, only one project (which I was fortunate to lead with Chicago colleagues) was foolish enough to wade out into the swamp of diagnostic errors. 9 At the time, we didn't fully realize the challenges (defining, measuring, and agreeing on taxonomies for diagnostic errors), but we were glad to be there from the beginning of efforts to address what is now recognized as the leading type of medical error, according to patient surveys, malpractice claims, and the ECRI Institute's safety priority polls. [10] [11] [12] I also worked on early efforts to leverage health information technology (IT) by linking lab and pharmacy data, 13, 14 demonstrate the value of integrating drug indication into computerized physician order entry (CPOE), 15 identify safety vulnerabilities in current CPOE systems, 16, 17 and conceptualize ways redesigning electronic clinical documentation redesign could prevent diagnostic errors. [18] [19] [20] We worked with primary care practices in Massachusettsthe PROMISES (Proactive Reduction in Outpatient Malpractice-Improving Safety, Efficiency, Satisfaction) Project-and showed in a randomized control trial that we could improve diagnostic safety and malpractice risk though a multifaceted intervention. 21, 22 But less important than recalling these past efforts is looking forward to what needs to be done next.

I hope next efforts can build on our prior work as well as areas I sense are particularly important but are currently underdeveloped or entirely neglected. We recently published a list of areas for improvement related to electronic medication prescribing. 17 For this interview, I was moved and challenged to create a list of diagnosis safety improvement ideas. This list (Table 1) , although a bit long, is not meant to be comprehensive. Rather, it is a personal vision regarding what sort of research and improvement projects are needed, a number of which we are currently working on. I encourage others to freely steal these ideas for your own research proposals and QI projects.

I pulled this list together just as the devastating impacts of the coronavirus crisis were beginning to be felt in the United States, upending our everyday work and lives and plans. As Bruce Springsteen said, Now all them things that seemed so important Well, mister, they vanished right into the air (from the song "The River"). The question this unprecedented public health crisis poses is whether these diagnosis improvement ideas are now irrelevant (or at least a luxury we can't afford to think about) in the face of the more pressing realities of COVID-19. Or perhaps they are more important than ever.

Consider the need to close the loop on abnormal test results, referrals, and unexplained symptoms. Think about all the distracted, deferred, delayed diagnostic processes that are occurring related to ordering and following-up of non-coronavirus tests, consults put on hold, symptoms that are being put on the back burner, along with physical-exam signs we may overlook entirely as we move to telemedicine and a single-minded focus on the novel coronavirus. Further, how do we better grapple with and communicate to patients all the uncertainties related to COVID-19 diagnosis and coronavirus test results with their imperfect sensitivity? 23 Thus it seems our generic diagnosis improvement efforts still have much to offer. And regardless of how pressing our worries are for pandemic viruses, cancer never sleeps. This leading cause of malpractice claims, missing cancer, will continue to haunt patients and clinicians until we have more robust processes for screening, assessing, and following patients.

You were a pioneer in studying medication safety, and you are still working actively in this area. What do you see as the most important advances in this area, and what are the most important problems to tackle moving forward?

There is a whole generation of younger physicians who have no idea what it was like to prescribe medications free-hand with pen and paper. When John Eisenberg testified before Congress in 1999, Senator Arlen Specter asked him about the quality of his handwriting, and he answered "It needs help." 24 Previously, John and I made many prescribing errors that are simply impossible to make in current CPOE systems. 25 But we should not be complacent about the advantages of electronic prescribing. I believe we have squandered much of its potential to help us achieve the World Health Organization (WHO) Global Patient Safety Challenge aim of "Medication without Harm." 26 These areas of failure include poorly designed decision support, introduction of new types of errors associated with using CPOE systems, frustratingly inefficient work-flows and screens that lead to dangerous workarounds, suboptimal linkages between prescribing systems and pharmacy dispensing databases resulting in prescribers not knowing what drugs have actually been dispensed by pharmacies and pharmacies not knowing when drugs are discontinued by physicians, inadequate monitoring of patients prescribed medications (including adverse effects and adherence), and failure of prescribing systems to help prescribers know the drug-of-choice for a particular indication. 17, 27, 28 One change we have been advocating is indications-based prescribing. Instead of starting a CPOE prescription by ordering a drug as is currently done, we propose entering the indication and letting the computer help select the best drug and dose. The computer already knows the patient's age, renal status, prior drugs tried and failed, and insurance coverage. More important, the computer would know the evidence-based guidelines regarding drugs of choice. Thus starting a prescription by entering the indication would allow for true decision support to flexibly guide selection of the best drug regimen, and would also capture the indication so it could be printed on the medication bottle label-something pharmacists and patients have been requesting for decades. 29 We designed an indications-based prescribing system prototype and compared it with the two leading CPOE systems (Epic, Cerner) and demonstrated it was safer, faster, and greatly preferred by the prescribers. 15

We realized that, just like with medication errors, if you can delineate the steps in the diagnostic process you can begin to identify the vulnerabilities and failure modes at each step. This is what led to the DEER (Diagnostic Error Evaluation and Research) taxonomy. 30 In 1999 the Institute for Safe Medical Practices (ISMP) investigated a Denver hospital where newspaper headlines reported the hospital's nurses had "killed" a newborn by giving a 10-fold fatal overdose of IV penicillin. The local district attorney charged the three nurses involved in the error with criminally negligent homicide. Using their process-oriented taxonomy as a lens to understand the error, ISMP found a very different picture. 31 Examining each step (prescribing, transcribing (this was prior to CPOE), dispensing, and administering), they found dozens of process errors and system failures at each step, including that the treatment itself was not necessary in the first place! (The Spanish-speaking mother had already been treated with penicillin, thus there was no need to treat the infant.)

In the DEER project we decided to borrow ISMP's medication safety approach in evaluating potential diagnostic errors. We delineated the steps in the diagnostic process (access, history, physical exam, lab testing, assessment, referrals, follow-up) and examined what could go wrong at each step. Based on a review of hundreds of potential diagnostic error cases, we developed the DEER taxonomy. But, as proud as we are to have made this contribution, I must confess this taxonomy was actually (at least in its origins) more of a retreat than a confident step forward. When the DEER investigators met each week to review cases in an attempt to understand their causes and ways to prevent the errors, we faced real challenges. We had trouble agreeing whether there was an error, or even what the correct diagnosis was and whether/when it should have been made sooner. 9 So we decided to step back to at least try to localize what went wrong in the diagnostic process.

So, for me, the origins and connections between medication safety and diagnosis safety run deep. Being able to work in both areas, cross fertilize what we learned, and see the interactions between drugs and diagnosis has been a real privilege (Appendix 1) One of the commonalities was the power-I'd say magic-of what you can learn and do when you remove blame. Instead of people being defensive or pointing fingers at someone else, everyone can roll up their sleeves and try to learn as much as possible about what happened, why, and how it can be prevented. Another powerful connection is the role of health informatics (HIT) in causing and preventing both types of errors. Electronic prescribing has definitely made prescribing safer. Likewise, electronic clinical documentation has great potential to help us make better diagnoses. [18] [19] [20] But in both cases we have fallen far short of realizing HIT's potential. So I would say is it a work in progress. 32 Back in 2011, David Bates and I listed 15 ways the EMR should be redesigned to better support diagnosis. 18 There has been relatively little progress in either transforming the EMR in the ways we described or modifying screens and workflows to be better able to use these potentially high leverage features. 20 One definition of a magic wand is a simple solution to a difficult problem. I want to be on record in acknowledging that many of these seemingly simple redesign solutions we offer are not that simple. Indications-based prescribing requires an up-front consensus about drugs-of-choice (though that's better than millions of prescribers concocting their own ad hoc choices every day) and disentangling the subtle conceptual and coding thickets related to the difference between a "diagnosis" and an "indication." 29 And leveraging the diagnosis-enhancing potential of electronic documentation will require coming to grips with the widespread use of scribes and the resulting changes in the ways physicians do, or do not, interact with the computer during the clinical encounter.

But there is one magic wand I would wave-real-time IT support for clinicians. Akin to Toyota's "stop the line" practices, any time a clinician is confused, is frustrated, gets an erroneous or troublesome alert, or has difficulty carrying out a task in their EMR, someone should be instantly on the line (by phone, or ideally on the screen) to help. The way this help should work is that the user would first show the support person what they had done to try to make the EMR behave to accomplish the desired task. No more "all you had to do is xyz," (rarely obvious in our non-intuitive systems). Rather the support person should record those attempted steps to take back to the organization and vendors' human factors engineers to continuously analyze, collate, and learn from the collective frustrations of EMR users. Aggregated data from these help-desk calls should be made publicly available, transparent, and accountable for researchers, regulators, and consumers. We collected help-desk data and safety reports related to electronic prescribing and found a wealth of questions and frustrations that had safety implications. 33 The purpose of this type of transparent, accountable learning system isn't just to make doctors happier or less frustrated; it is to redesign the systems to make them safer and more efficient for everyone. Done right, this magic wand multiplies to 3 or even 3,000 magic wands.

What do you see as the most encouraging progress made in the field of patient safety? And what aspects of trying to improve safety have proved to be the most frustrating for you personally?

The most encouraging, and I would like to think enduring, accomplishment of the patient safety movement is creating greater transparency, legitimacy, and institutionalization of safety. In the early days, raising problems was generally met with resistance, defensiveness, secrecy, and even fingerpointing back at the messengers for rocking the boat or unnecessarily exposing the organization to malpractice claims. There was a culture of burying rather than sharing our mistakes. A turning point came in 2001 when The Joint Commission began to require disclosure of unanticipated outcomes of care. 34 People like Lucian Leape, Tom Gallagher, Steve Kraman, Rick Boothman, and in Massachussets, Ken Sands and our PROMISES team helped hospitals and offices operationalize apology and disclosure programs. [35] [36] [37] There is no turning back. We are currently working with AHRQ to develop a tool doctors' offices can use to self-measure their outpatient diagnosis safety practices and culture, something I believe is an important and needed step forward. 38, 39 The most discouraging thing about our safety efforts is the failure to more meaningfully engage front line staff (such as physicians, nurses, pharmacists, and others). Many perceive quality and safety activities as perfunctory, box checking, additional burdens, and mindless annual certifications, rather than what should be the most joyful, rewarding, and strongly supported part of their work. Why isn't there as much, if not more, satisfaction in and support for taking care of the system and our future patients as there is in caring for the individual patient in front of us today? It is this alienation from the QI enterprise that so bothered Avedis Donabedian, who deplored "managerial, mechanistic" rather than "participatory" approaches to quality. 40 This was also recently highlighted by Don Berwick, who describes how he changed his mind about quality programs that place metrics at the center of quality activities, rather than in their rightful place as tools to empower those working in the system to learn and improve their own work. 41 The cynicism-breeding effects of managerial approaches ultimately corrupt the QI mission and squander its most valuable asset-the hearts and minds of health care workers.

It has been a special privilege for me to bring the three decades of learning, insights, and experience I had at Cook County Hospital to Harvard. I realize this is the reverse of the usual academic construct! Yet I learned so much from my patients, the dedicated staff, and quality advocates at County about system errors, engagement, compassion, advocacy, humility, and personally connecting with our patients, that I felt I had a lifetime of knowledge and relationships to draw on. Coming to Boston (Brigham and Women's Center for Patient Safety Research; Harvard Medical School Center for Primary Care) to work for the past decade with many of my lifelong heroes in quality, safety, and health reform, likewise has been a privilege for which I am grateful.

Although some might consider me a political radical (I am a longtime supporter of single payer health insurance, 42 which is now needed more than ever), I am proud to have helped stake out fundamental principles of what it means to be more conservative in the way we use medications and diagnostic testing. 43.44 Nobel prizes are given annually for breakthrough discoveries in basic sciences. However, preventing widespread indiscriminate misuse of the "latest and greatest" technologies that lack evidence of benefit and/or are harming patients, can potentially save many more lives. It is nice to have an award recognizing this. We are also pleased that the IHI Open School has recognized the importance of conservative prescribing and has just gone live with an Open School Course that we helped prepare devoted to teaching conservative prescribing principles.

Thank-you for this question, which feels like a perfect way to conclude our conversation. I had not planned to have clinician-patient relationships as one my areas of quality and safety research; it was thrust on me by a series of events calling into question my own behavior and care for my primary care patients. 45 I had assumed that applying QI principles in very personal ways to my everyday care was part of putting into practice the type of patient-centered care the IOM advocated in their landmark Crossing the Quality Chasm report. 46, 47 The IOM proposed ten new rules to guide patient-clinician relationships that emphasized care based on continuous healing relationships and responding to patients' preferences, values and needs. For me, that meant genuinely knowing my patients and, where needed, going the extra mile to help them, even if that meant stepping out of the traditional doctor role of making diagnoses or writing prescriptions. It means on rare occasions helping them pay for medicines or a ride home, visiting them at their homes, helping them get a job, sharing music, attending weddings, graduations, bar-mitzvahs, or funerals. Although it's necessary to be mindful of boundary issues and power disparities, such human relationships would seem to be an essential part of good quality care. Yet it turns out this touches a raw nerve in medicine related to real controversies, which we have explored in recently published research. 48 There is a clash between rules that rigidly proscribe certain behaviors, and what I would argue is a more ethical, commonsense approach that weighs risks and benefits and takes into consideration the context of our actions. To re-humanize medicine, we will need to put the patients, not the rules, at the center. If we are guided by a sense of social solidarity, 49 this can bring us closer to our patients, while giving more meaning to and energizing our work. I believe John Eisenberg wouldn't want it any other way. -EMR/note reorganization to enhance ability to quickly locate clinical summary/assessment -Designing standardized, validated constructs and tools for assessing the assessment (both qualitatively and defined metrics) and best practices to model -Support for higher quality assessment documentation-time, IT tools (especially voice recognition and cognitive support) 1 -Context-aware decision support to help clinician select the most appropriate test based on clinical question/concern (indication-based ordering), prior tests/results, method for obtaining specimen or preparing patient, test availability/financial constraints 5. Test/Referral followup Significantly more reliable systems for closing the loop to ensure error-free follow-up on test results and referrals -Closely coupled ordering-reportingacknowledging-tracking systems that ensure any "unclosed loops" are visible and (where warranted) action(s) reliably taken to followup -Requires complement of HIT, coordinated interactions between clinicians and lab/radiology/specialists, consensus-based rules, leadership support and resources, and patient engagement.

Enhancing clinician-patient continuity and personal relationships to ensure doctors know their patients (and vice versa), a prerequisite for good diagnosis -Series of measures that overcome factors that pervade current system that disrupt/challenge continuity (e.g., narrow or changing networks tied to private insurance, forced switches related to job changes, stresses on primary care) -Positive enhancements to better support primary care supply, efficiency, availability, joy, cultural connections, to strengthen longitudinal caring relationships 4 

Ensuring both clinicians and patients feel they have adequate time during and between encounters to meaningfully perform diagnosis work -Adequate encounter time for new and follow-up patients -Building in dedicated time/space between encounters for just-in-time charting, cognitive work, and where needed reviewing old records and online information resources -Design and implement formal interencounter "watchful waiting" systems and patient plans that leverage and optimize teamwork, HIT, patient engagement and conservative diagnosis principles. 5 

Re-engaging clinicians in joy and fun of challenging diagnosis, and valuing their efforts to improve; countering alienation from practice production pressures/management -Need top down (system redesign, leadership commitment) and bottom up (career-long professional commitment) approaches -Discerning and designing countermeasures needed to convert current alienation from quality improvement apparatus and "moral injury" sentiments, 6 to one of personal ownership where clinicians' hearts and minds are actively engaged and where they are encouraged, enjoy, and are rewarded for daily efforts to improve quality 9. Speaking up How to design, reinforce, operationalize, and reward a culture of speaking up when there are diagnostic uncertainties and questions about diagnostic assessments and course -180-degree turnaround in humility deficit/monopoly held by doctors as exclusive and unchallengeable source of diagnostic knowledge -Broaden to include nurses, pharmacists, lab, and especially patients and family members 10. Shared decisionmaking support Need for tools to better guide informed conversations about screening (e.g., cancer) and other diagnostic evaluation conversations -Enhanced graphic representations of screening benefits and harms to help guide clinicians and patients in understanding nature, magnitude, and relevance of tests 7 11 . EMR redesign to support cognition Visual display, data visualization, workflow redesign to support more useful/institutive/integrated/efficient -Serious efforts to advance state of the art in the 10 domains for HIT to support diagnosis that we previously outlined and found paucity of efforts and evidence 8 -Key areas include: aids to facilitate information gathering, enhanced display of information, differential diagnosis generation, Bayesian calculators, access to reference information and guidelines, screening reminders/trackers, real time consultation tools 8 To ensure that lab signals of a potential medication-related adverse event or symptom(s) are recognized/diagnosed in more timely ways -Automated flagging of any active symptoms or lab abnormalities that could be due to known or potential drug etiologies related to medications patients are taking 14. Failure to consider Intelligent, automated prompts to support clinicians in generation of differential diagnosis and/or suggest diagnosis they may have overlooked -Enhanced differential diagnosis generators that are more integrated in work-flow and more helpful in prioritizing most likely and critical diagnoses (rather than display a long undifferentiated list) 15 Ensuring that efforts to not miss diagnoses do not lead to unnecessary, harmful testing and overdiagnosis 3, 12 -Integrating a series of principles that demonstrate ways over-and under-diagnosis are not competing opposites but rather two sides of same coin. -Strengthening primary care relationships, understanding testing harms, linkages between diagnosis and treatment 5 SOAP, subjective, objective, assessment, plan; EMR, electronic medical record; IT, information technology; HIT, health information technology; AI, artificial intelligence.

Often errors of commission More often errors of omission Easier to pinpoint time and place May occur over extended time, encounters Less ambiguous, at times clearer deviations of order, protocol Considerable judgment, ambiguity, disagreement deciding whether and when error occurred Often blamed on sharp-end nurses, pharmacists, physician/prescribers who "commit" the error, but more often distributed among people, systems, technology, communication processes

Physicians often held responsible for their failure to consider a diagnosis, order needed test(s), follow-up, but most errors are multifactorial with contributing roles of lab, radiology, specialty referrals/testing, uncertainty, and patients Unless recognized at the time, often/easily overlooked by staff and patient Misdiagnosis often missed, but serious/non-self-limiting diagnoses can evolve with correct dx ultimately being manifest/recognized sooner (infection) or later (cancer) Robust evidence that medication errors can be reduced with HIT and electronic decision support (CPOE, CDS, bar coding)

Still lacking good evidence about best ways to prevent and mitigate; promising potentials for HIT presently underdeveloped Subject of considerable initial patient safety activity Emerging only in recent years (malpractice data, NAM report) as important focus of safety efforts Being more conservative, ordering fewer drugs, recognized as a way to avoid; often drug-related adverse events lead a prescriber to prescribe fewer drugs in future Occurrence can lead to clinician future over-ordering to avoid missing diagnoses; however, such less-conservative, "defensive medicine" ordering practices also can lead to potentially harmful adverse effects Can have medication safety "5 Rights" all done correctly, yet if diagnosis is wrong treatment is often wrong Failure to diagnose a drug cause for a particular symptom/sign/test abnormality represents one of the most important types of misdiagnosis, since often it is imperative to discontinue the drug both clinically and ethically

Electronic Clinical Documentation

Minimizing diagnostic error: the importance of follow-up and feedback

Exploration of an automated approach for receiving patient feedback after outpatient acute care visits

Connecting With Patients-The Missing Links

Ten Principles for More Conservative, Care-Full Diagnosis

They're suffering from moral injury

When Guidelines Recommend Shared Decision-making

Use of health information technology to reduce diagnostic errors

Improving Diagnosis in Primary Care One Case at a

Use of an Expedited Review Tool to Screen for Prior Diagnostic Error in Emergency Department Patients

Empanelment: A foundational component of primary health care

Update on Medical Overuse: A Review

Derived Thresholds: Determining the Diagnostic Probabilities at Which Clinicians Initiate Testing and Treatment

Clinical scholars and their program: Children of the sixties in the eighties

Addressing the Issue of Chronic, Inappropriate Benzodiazepine Use: How Can Pharmacists Play a Role?

Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial

A meta-analysis of the effect of estrogen replacement therapy on the risk of breast cancer

Mortality and morbidity in patients receiving encainide, flecainide, or placebo: the Cardiac Arrhythmia Suppression Trial

Inpatient theophylline toxicity: preventable factors. Annals of internal medicine

Improving Diagnosis in Primary Care One Case at a

Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project

Primary Care Closed Claims Experience of Massachusetts Malpractice Insurers

National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care

Linking laboratory and pharmacy: opportunities for reducing errors and improving care

Missed hypothyroidism diagnosis uncovered by linking laboratory and pharmacy data. Archives of internal medicine

Comparison of a Prototype for Indications-Based Prescribing With 2 Commercial Prescribing Systems

Computerised prescribing for safer medication ordering: still a work in progress

A prescription for enhancing electronic prescribing safety

Can electronic clinical documentation help prevent diagnostic errors

Use of health information technology to reduce diagnostic errors

Electronic Clinical Documentation

Addressing Ambulatory Safety and Malpractice: The Massachusetts PROMISES Project

Randomized Trial of Reducing Ambulatory Malpractice and Safety Risk

COVID-19 Testing: The Threat of False-Negative Results

Joint hearings before the Subcommittee on Labor, Health and Human services, and Education, and Related Agencies committee on appropriations. Committee on Health, Education, Labor, and Pensions and the Committee on Veterans' affairs United States Senate

Computerized prescribing: building the electronic infrastructure for better medication usage

Patient safety: making health care safer. World Health Organization

Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems

Beyond the prescription: medication monitoring and adverse drug events in older adults

Incorporating medication indications into the prescribing process. The Bulletin of the American Society of Hospital Pharmacists

Diagnostic error in medicine: analysis of 583 physician-reported errors. Archives of internal medicine

Medication errors: integrating individual and system accountability

Computerised prescribing for safer medication ordering: still a work in progress

Computerized prescriber order entry-related patient safety reports: analysis of 2522 medication errors

When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals.Massachusetts Coalition for the Prevention of Medical Errors

Advocacy: the Lexington Veterans

Doing right by our patients when things go wrong in the ambulatory setting

Under Development: New Diagnostic Safety Supplemental Item Set for the

The Elusive and Illusive Quest for Diagnostic Safety Metrics

Striving for quality in health care: an inquiry into policy and practice

Keynote Three: I have changed my mind

A better-quality alternative: Single-payer national health system reform

Principles of conservative prescribing. Archives of internal medicine

Ten Principles for More Conservative, Care-Full Diagnosis

Crossing Boundaries-Violation or Obligation?

Building a better delivery system

What 'Patient-Centered'Should Mean: Confessions Of An Extremist: A seasoned clinician and expert fears the loss of his humanity if he should become a patient

Professional-Patient Boundaries: a National Survey of Primary Care Physicians' Attitudes and Practices

decolonizing solidarity: Gracias Galeano