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A Report to the Patient Safety Committee

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  • When it comes to heath services, we must assume the burden for structuring systems that will allow providers and patients to thrive irrespective of their situation. In other words, we might be the trouble.
  • Presenters
  • AGH Institutional Details
  • Institutional Details Continued
  • Details specific to the patient.
    5) 20 year old history of schizophrenia-
    Multiple treatment relapses
  • Methods used to evaluate the case, target points of intervention, and develop recommendations.
    2/5: Extrapolation refers to the implications of these interventions with regard to developing long-term improvements at the systems level (both internal and external to the institution)
  • Overview of results from our investigation: Delineation of Adverse Events and Near-Misses
    *Self-Extubation – asterisk indicates that while this event was not specifically identified as a point of investigation, it was still identified as a adverse event that could have been prevented..
  • The patient’s overdose was treated solely from a physical health perspective, resulting in patient’s self-harm risk remaining unassessed.
    --Although psych was involved, the primary intent seemed to be for medication management and not evaluation of self-harm
    Patient’s medication was transferred to her room and left unsecured, resulting in persistent availability of Clozaril to the patient.
    Informal and undocumented communication between front-line employees resulted in the unproven assumption of polysubstance abuse, contributing to a presumed diagnosis and treatment plan for unintentional Clozaril overdose.
    The patient’s PMH was initially obtained solely from a pill bottle found on the patient, contributing to a presumed diagnosis and treatment plan for unintentional Clozaril overdose.
    Patient’s medication was identified solely by a pill bottle found on the patient by the ER staff without pharmacist involvement, contributing to a presumed diagnosis and treatment plan for unintentional Clozaril overdose.
    Parallel, informal, and undocumented communication between front-line workers regarding the patient’s self-harm risk resulted in suspicions of suicidal intentions being communicated to only a minority of care team members.
  • Develop a section of the AMR specifically dedicated to patient psychosocial issues
    Includes psychosocial information tab
    Automatic prompts for psychiatry referral in case of overdose
    Automatic prompts for self-harm risk assessment in cases of overdose
    Identify patient as possible self-harm risk on ID bands
    Establish procedures for patients at possible risk for self harm
    Meal trays with plastic utensils and paper flatware only
    Removal of all possibly harmful items from room
    Standard list of items
    Sitter in patient’s room
  • HCC was not involved within 36 hours of admission which was a failure to follow an existing procedure that resulted in delayed identification of the need to notify the patient’s employer.
    Inaccurate communication between front-line providers resulted in incorrect assumptions concerning possibility of Rx interactions
    Inadequate behavioral assessment may have resulted in decrease monitoring of/attention to Pt
    Inadequate provider staffing in ICU may have increased the probability of Pt self-extubation
    Poor availability/communication of sedation protocols increased the likelihood of inadequate sedation
    Poor availability/communication of agitation management protocols may have increased the likelihood of inadequate sedation
  • Adverse Event #1: Self-Extubation
  • Timeline for S-E
  • Flow Diagram for Self-Extubation
  • Root Cause Overview for S-E
  • Delayed involvement of pharmacist resulted in delayed/insufficient toxicology assessment
    Inaccurate communication between front-line providers resulted in incorrect assumptions concerning possibility of Rx interactions
    Inadequate behavioral assessment may have resulted in decrease monitoring of/attention to Pt
    Inadequate provider staffing in ICU may have increased the probability of Pt self-extubation
    Poor availability/communication of sedation protocols increased the likelihood of inadequate sedation
    Poor availability/communication of agitation management protocols may have increased the likelihood of inadequate sedation
  • Collaborative rounding b/t psych and SW, formalized assessments, AMR enhancement as described below
    P&P: Assessments for self-harm risk, med ID, self-harm precautions
    AMR: Increase responsiveness and feedback; make more user-friendly regarding psychosocial issues
    Care team roles: redefine HCC, expand role of SW and pharmacist
  • Transcript

    • 1. A Report to theA Report to the Patient Safety CommitteePatient Safety Committee of Arizona General Hospitalof Arizona General Hospital Prepared by Members of the University of Missouri-Columbia Interdisciplinary Workgroup for the CLARION INTERPROFESSIONAL CASE COMPETITION SPRING 2005
    • 2. AGHAGH INTRODUCTIONS • Ashley Mahon – Accelerated Option BSN, RN Program – UMC School of Nursing • Russell McCulloh – 4th Year, MD Program – UMC School of Medicine • Kevin Norris – 3rd Year, PT Program – UMC School of Health Professions • Brian Stout – 3rd Year, MHA/MBA Dual Degree Program – UMC Schools of Medicine & Business
    • 3. She “might be trouble”She “might be trouble” -Bus Driver-Bus Driver
    • 4. AGHAGH PRESENTATION OVERVIEW • Case Overview • Methods of Analysis • Major Findings • Specific Findings – Recommendations/Action Plan – Tracking Indicators – Cost Analysis • Systems Issues • References/Acknowledgments
    • 5. AGHAGH CASE OVERVIEW • Arizona General Hospital: – Tertiary care center – 620 bed-facility – 97 Behavioral Health Beds • AGH Values: – Dignity – Collaboration – Stewardship – Excellence
    • 6. AGHAGH CASE OVERVIEW • Part of Southwest HC System (SWH) Flagship for HC delivery in Maricopa Co. 10 affiliated clinics • Clinical Expertise Centers of Excellence Behavioral Health Women’s Health Rehabilitation Cardiovascular services Neuroscience Oncology Orthopedics Spine Care
    • 7. AGHAGH CASE OVERVIEW • 36 year old female • 20 year history of schizophrenia • Admitted for decreased mental status • Treated for suspected overdose • Self-administered medication overdose in hospital • 3-week stay in BHU • Discharged to home • Readmitted seven weeks later for relapse of psychotic symptoms and alcohol intoxication
    • 8. AGHAGH METHODS • Investigation: – Identification of Major Events – Causal Flow Analysis – Root-Cause Analysis (VA-NCPS) – Identification of Contributing Factors • Remediation: – Literature Review – Development of Recommendations – Progress Assessment – Cost Analysis – Extrapolation
    • 9. AGHAGH MAJOR FINDINGS • Three adverse events were identified: – Self-Induced Clozaril Overdose – Job/Coverage Loss & Rehospitalization – Self-Extubation* • Self-Induced Overdose: – Unsuccessful suicide attempt – Near-miss of a reportable JCAHO sentinel event: “Any suicide of a patient in a setting where the patient is housed around-the-clock”
    • 10. Self-InducedSelf-Induced Drug OverdoseDrug Overdose
    • 11. AGHAGH Self-Induced Overdose Timeline
    • 12. AGHAGH Self-Induced Overdose Flow Diagram
    • 13. AGHAGH Self-Induced Overdose RCA • Root Cause Statement: “Level of patient observation and access to potentially toxic medications resulted in increased possibility of self-induced overdose.” • Three contributing factors domains were identified
    • 14. AGHAGH Care Team Communication
    • 15. AGHAGH Care Team Role Definition
    • 16. AGHAGH Policies & Procedures
    • 17. AGHAGH Self-Induced Overdose Ishikawa
    • 18. AGHAGH Self-Induced Overdose: Contributing Factors • Care Team Communication – Parallel and informal evaluation and communication of self-harm risk – Informal assumption of polysubstance abuse • Care Team Roles – Medication identified solely by ER staff – Primary focus on only physical health aspects of admission • Policies & Procedures – Persistent access to patient of potentially toxic medications – PMH gathered solely from patient’s medication bottle
    • 19. AGHAGH Self-Induced Overdose: Recommendations • Care Team Communication – AMR “tab” dedicated to psychosocial issues1 • Care Team Roles – All pt home meds are to be ID by pharmacist2 • Policies & Procedures – Develop a standard protocol for evaluation & management of all overdose patients3 – Establish procedures for pts. at possible risk for self harm1,4 – Establish security procedures for the intake, storage, and disposition of pt home meds2 – Similar policy for potentially harmful pt. items2
    • 20. AGHAGH Self-Induced Overdose: Tracking Indicators 1. Suspected overdose patients assessed for self-harm risk* 2. Employees scoring 70% or greater on knowledge assessment of behavioral health training courses* 3. Home medications stored securely* *All indicators are percentage-based; goals for implementation are to be set at 100% compliance
    • 21. AGHAGH Self-Induced Overdose: Cost Analysis • Incurred costs – Room sitters (personnel-dependent) – Time/resource demands for training personnel re: new assessment procedures – Monitoring/ongoing risk assessment • Cost-neutral measures – AMR changes covered by IT contract • Estimated savings – Reduced risk of emergent intervention
    • 22. AGHAGH Self-Induced Overdose: Dollars and Sense Comparative Costs of Sitter vs ICU Stay With Intervention: Room Sitter Wage 15.00$ Est. # of Hours Surveillance 24 Observation Costs 360.00$ W/O Intervention: Avg. Cost of Stay (ICU): 44,845.00$ A Avg. LOS in Days (ICU) 6.01 A Avg Cost/Day (ICU) 7,461.73$ A Est. Savings W/ Intervention: 7,101.73$
    • 23. Job/Coverage LossJob/Coverage Loss and Rehospitalizationand Rehospitalization
    • 24. AGHAGH Job/Coverage Loss & Rehospitalization Timeline
    • 25. AGHAGH Job/Coverage Loss & Rehospitalization Flow Diagram
    • 26. AGHAGH Job/Coverage Loss & Rehospitalization RCA • Root Cause Statement : “Level of social services involvement led to the patient’s job & coverage loss and ultimately resulted in patient’s relapse & readmission to the hospital.” • Three contributing factor domains were identified
    • 27. AGHAGH Care Team Communication
    • 28. AGHAGH Inadequate Social Services
    • 29. AGHAGH AMR Usage
    • 30. AGHAGH Job/Coverage Loss & Rehospitalization Ishikawa
    • 31. AGHAGH Job/Coverage Loss & Rehosp.: Contributing Factors • Care Team Communication: – Care teams engaged in parallel and informal communication • Coordination of Social Services: – Patient assigned to HCC – Currently defined roles for HCC and SW – HCC only involved near end of pt’s stay • AMR Usage: – Hospital staff unfamiliar with documenting psycho-social information into the AMR – Incomplete integration of AMR with organizational culture
    • 32. AGHAGH Job/Coverage Loss & Rehosp.: Recommendations • Care Team Communication – Psych team and SW make daily rounds together for all primary diagnoses of mental illness, psychosis, and drug overdose5 – Fully integrated multi-disciplinary teams • Coordination of Social Services – Redefine the role of the HCC6,7,8 – Automatic referral to SW in cases with primary dx. of mental illness, psychosis, or drug overdose • AMR Usage – AMR “Tab” for psycho-social information – Formal mechanism for staff feedback
    • 33. AGHAGH Job/Coverage Loss & Rehosp.: Tracking Indicators 1. Staff satisfaction rate with AMR (20% increase from baseline) 2. Voluntary exit survey for patients receiving Psych/SW team care 3. Percent of pts. admitted with diagnosis of mental illness, psychosis, or drug overdose, assessed by SW (100%) 4. Percent of pts seen by HCC within: - 36 hours of admission (>95%) - 48 hours of admission (100%) 5. Number of readmissions due to mental illness, psychosis, or drug overdose (10% reduction)
    • 34. AGHAGH Job/Coverage Loss & Rehosp.: Cost Analysis • Cost Neutral Recommendations: – AMR changes (provided through IT contract) – Social Worker/Psych rounds – Referral policies • Incurred Costs – Additional HCCs (case managers)9 • Savings – Reduce number of psych readmissions6 – Reduced LOS by 10% with multi-disciplinary rounds5 – Reduced per-patient cost of stay by up to 16% with multi-disciplinary rounds5
    • 35. AGHAGH Job/Coverage Loss & Rehosp.: Dollars and Sense Cost of Universal Case Management Number of Additional HCCs Needed: 10 Annual Salary (Case manager) Acute care $53,000 B Cost of Providing Case Management to All Pts: $530,000
    • 36. AGHAGH Job/Coverage Loss & Rehosp.: Dollars and Sense Decreased LOS (Psych Services) Avg. LOS in Days (Psych): 9.47 A Decrease: 10% Post-Intervention LOS in Days (Psych) 8.52 Avg Cost of Stay (Psych): 8,757.00$ A Avg Cost/Day (Psych): 1,027.46$ A Per Patient Cost W/O Intervention 9,730.00$ Per Patient Cost W/ Intervention 8,757.00$ Savings Per Psych Admission $973.00 Avg. # of Psych Admissions 1,041.00 A Total Annual Savings 1,012,893.00$ Decreased Cost of Stay (Psych Services) Avg. Cost of Stay (Psych): 8,757.00$ A Estimated Decrease: 16% Avg Cost of Stay W/ Multi-D Rounding 7,355.88$ Savings Per Psych Admission 1,401.12$ Avg. # of Psych Admissions 1,041.00 A Total Annual Savings 1,458,565.92$
    • 37. Self-ExtubationSelf-Extubation
    • 38. AGHAGH Self-Extubation Timeline
    • 39. AGHAGH Self-Extubation Flow Diagram
    • 40. AGHAGH Self-Extubation RCA • Root Cause Statement : “The level of sedation & agitation management increased the likelihood of patient self-extubation” • Three major contributing factor domains were identified
    • 41. AGHAGH Care Team Communication
    • 42. AGHAGH Policies & Procedures
    • 43. AGHAGH Scheduling
    • 44. AGHAGH Self-Extubation Ishikawa
    • 45. AGHAGH Self-Extubation: Contributing Factors • Care Team Communication: – Time/location of pharmacist involvement – Communication b/w front-line providers • Policies & Procedures: – Extent of behavioral assessment – Availability/use of agitation management protocols – Availability/use of sedation and weaning protocols • Scheduling: – Provider staffing-level in ICU
    • 46. AGHAGH Self-Extubation: Recommendations • Care Team Communication: – Ensure timely urine/serum toxicology screens in conjunction with overdose protocols – Develop AMR flag for pharmacist consult in all cases involving drug overdose • Policies & Procedures: – Institute routine use of agitation management protocols by ICU staff (Ramsay)10 – Institute use of sedation protocols in ICU11,12 – Institute use of weaning protocols in ICU10,13 • Scheduling: – Evaluate adequacy of ICU staffing/training10,14,15
    • 47. AGHAGH Self-Extubation: Tracking Indicators 1. Incidence of self-extubation (ICU) 2. Length of ventilator support (ICU) 3. ICU pt-nurse staffing ratios (1.5-1.7) 4. Number of pts (per 100 intubated pts) that score below 3 on two consecutive hourly Ramsay Assessments (Zero) 5. Percent of overdose pts whose records include RPh consult notes (100%) 6. Percent of overdose pts whose urine/serum toxicology screens are ordered w/in 1 Hr of admit to ER (100%)
    • 48. AGHAGH Self-Extubation: Cost Analysis • Incurred Cost: – Increased ICU Staffing? – Physician/RPh Consult Fees – Implementation of protocols/training – Monitoring/ongoing risk assessment • Estimated Savings: – Decreased LOS in ICU (Decrease of 3.5 days)16,17 – Shorter Duration of Ventilator Support (Decrease of 2.5 days17 ; between 63 and 89% of SEs do not require reintubation10 ) – Costs of Reintubation (>40% Decrease)11
    • 49. AGHAGH Self-Extubation: Dollars and Sense Decreased LOS in ICU Decrease in Days: 3.5 Avg LOS in Days (ICU) 6.01 A Avg Cost of Stay (ICU): 44,845.00$ A Avg Cost/Day (ICU): 7,461.73$ Avg. # of ICU Patients/Yr: 4,991 A Annual Cost W/O Intervention 223,821,395.00$ Annual Cost W/ Intervention 93,476,156.65$ Annual Savings 130,345,238.35$ Decreased Ventilator Support Decrease in Days: 2.5 Avg Time on Ventilator in Days (ICU) 12.5 C Cost/Day (Ventilator Support): 200.00$ C Avg. # of Patients on Ventilator Support/Yr: 314 C Annual Cost W/O Intervention 784,393.94$ Annual Cost W/ Intervention 627,515.15$ Annual Savings 156,878.79$ Decreased Self-Extubation Costs Percent Decrease: 40% Avg. Rate of Self-Extubation 17% C Avg Number of Self-Extubations/Year 102 C Avg. Rate of Self-Extubation W/ Intervention 10.2% Cost of Reintubation $117 D Annual Cost W/O Intervention 11,934.00$ Annual Cost W/ Intervention 7,160.40$ Annual Savings 4,773.60$
    • 50. ““The Big Picture”The Big Picture”
    • 51. AGHAGH Recommendation Summary • Communication • AMR/organizational culture integration • Policies and Procedures • Expansion of care team member roles • Supporting AGH mission and values – Dignity – Collaboration – Stewardship – Excellence
    • 52. AGHAGH What If… • Psych would have been more actively involved in patient care? Risk for self-harm would have indicated need for 1:1 staffing and/or suicide observation in ICU and suicide observation in Ward 10A • Pharmacy would have been more actively involved in patient care? Patient and drug ID would have been confirmed Patient PMH might have been available Concerns over sedative interactions might have been dismissed
    • 53. AGHAGH What If… • Social Services would have been more actively involved in patient care? Patient job/coverage loss might have been avoided altogether Patient would have had access to local mental health resources and “safety net” coverage • All three domains had been aligned with delivery of acute care? No adverse events? Patient would have certainly left our institution better off than when she arrived (in many ways)
    • 54. AGHAGH Targeting Continuity of Mental Health Services • Within the Institution – Mental Health Services – Pharmacy – Social Services – Acute/Chronic Care • Within the Community: – Provider/MCO Collaboration – Partnerships – Regional Leadership
    • 55. AGHAGH Future Directions: • Increase pharmacy integration:  Discharge Planning/Consultation18,19,20  Pharmacy and Therapeutics Committee18,19  Collaborative Drug Therapy18,19  Medication Reconciliation21  Psychiatric Pharmacist22,23 • Integrating social services & behavioral health:  Functional Integration Team18 (AGH BHCE)  Wellness Recovery Action Plans24 (WRAP) • Ongoing collaboration between:  AGH & community pharmacies  AGH & satellite clinics  SWH & ValueOptions25,26
    • 56. AGHAGH Concluding Remarks • Consistent with: – Our institutional mission – IOM & IHI vision of the future – Our patients’ needs/rights to access & receive safe, reliable, and comprehensive care ““It doesn’t work to leap a twenty-foot chasmIt doesn’t work to leap a twenty-foot chasm in two ten-foot jumps”in two ten-foot jumps” -American Proverb
    • 57. A Report to theA Report to the Patient Safety CommitteePatient Safety Committee of Arizona General Hospitalof Arizona General Hospital Prepared by Members of the University of Missouri-Columbia Interdisciplinary Workgroup for the CLARION INTERPROFESSIONAL CASE COMPETITION SPRING 2005
    • 58. AGHAGH References 1. Dlugacz, Y.D., Restifo, A., Scanion, K., Nerlson, K., et al. (2003). Safety Strategies to Prevent Suicide in Multiple Health Care Environments. Joint Commission Journal on Quality and Safety, 29(6), 267-278. 2. Harry S. Truman Memorial Veterans Hospital- Pharmacy operations and drug procedures. December 30, 2004. 3. Harry S. Truman Memorial Veterans Hospital- Prevention and management of disturbed behavior. April 22, 2004. 4. Harry S. Truman Memorial Veterans Hospital- Management of suicidal policy. April 26, 2004. 5. Curley, C., McEachern, K. E., Speroff, T. (1998). A Firm Trial of Interdisciplinary Rounds on Impatient Medical Wards: An Intervention designed using continuous quality improvement. Med Care, 36(8), AS4-AS12. 6. Cox, W.K., Penny, L.C., Statham, R.P., Roper, B.L. Admission intervention team: medical center based intensive case management of the seriously mentally ill. Care Management Journals, 4(4), 178-184.
    • 59. AGHAGH References 7. Rubin, A. Is Case Management Effective for People With Serious Mental Illness? A research review. Health & Social Work, 17(2), 138-150. 8. Wickizer, T.M., Lessler, D. Do Treatment Restrictions Imposed by Utilization Management Increase the Likelihood of Readmission for Psychiatric Patients? Medical Care, 36(6), 844-850. 9. 2003 Case Management Salary Survey Results. In: Advance for Providers of Post-Acute Care. May/June 2003, 51-54. 10. Maccioli GA et al. (2003). Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: Use of restraining therapies-American College of Critical Care Medicine Task Force 2001-2002. Critical Care Medicine. 31(11), 2665-2676. 11. Wagner IJ. (1998). A sedation protocol to prevent self- extubation. Chest. 113(5),1429. 12. Powers J. (1999). A sedation protocol for preventing patient self-extubation. Dimensions of Critical Care Nursing. 18(2), 30-4.
    • 60. AGHAGH References 13. Razek T et al. (2000). Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation. Journal of Trauma-Injury Infection and Critical Care. 48(3), 466-9. 14. Bray K et al. (2004). British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. BACCN Nursing in Critical Care. 9(5), 1-19. 15. Martin B and Mathisen L. (2005). Use of physical restraints in adult critical care: A bicultural study. American Journal of Critical Care. 14, 133-142. 16. Ramsay MAE. (2005). How to use the Ramsay Score to address the level of ICU sedation. Referenced Wed Document. Available at: http://5jsnacc.umin.ac.jp/How%20to%20use%20the%20Ramsa . Accessed on March 23rd, 2005. 17. Kress JP, Pohlman AS, and Hall JB. (2002). Sedation and analgesia in the intensive care unit. American Journal of Respiratory Critical Care Medicine. 166, 1024-1028.
    • 61. AGHAGH References 18. IHI 100,00 Lives Campaign. (2004). Getting Started Kit: Prevent Adverse Drug Events (Medication Reconciliation). The Institute for Health Improvement. Available at www.ihi.org . 19. Paone D, Levy R, and Bringewatt R. (1999). Integrating pharmaceutical care: a vision and a framework. The National Chronic Care Consortium & The National Pharmaceutical Council. Available at www.npcnow.org/resources/PDFs/IPCvisionpaper.pdf. 20. Saunders, S.M., Tierney, J.A., et al. (2003). Implementing a pharmacist-provided discharge counseling service. AMJHSP, 60, 1101-1103. 21. Rosen CE and Holmes S. (1978). Pharmacist’s impact on chronic psychiatric outpatients in community mental health. American Journal of Hospital Pharmacy. 35(6), 704-8. 22. Kaushal R and Bates DW. (2005). Chapter 7: The clinical pharmacist’s role in preventing adverse drug events. AHRQ Patient Safety Manual. Available at www.ahrq.gov/clinic/ptsafety/chap7.
    • 62. AGHAGH References 23. Arizona State Hospital. Wellness Recovery Action Plans (WRAP). http://www.azdhs.gov/azsh/patient_programs.htm. 24. ACP-ASIM. (2000). Pharmacist Scope of Practice. Position Paper. American College of Physicians – American Society of Internal Medicine. www.acponline.org/hpp/pospaper/pharm_ scope.pdf. 25. ValueOptions of Arizona. Assertive Community Treatment (ACT). http:// www.valueoptions.com/arizona/en/programs/act.htm 26. ValueOptions of Arizona. Contract implementation fact sheet: Recovery for adults with serious mental illnesses. Available at: http:// www.valueoptions.com/arizona/en/publications/fact_sheet_adu .
    • 63. AGHAGH Data Sources for Cost Analyses • A - University Health System Consortium Clinical Database; January through December 2004 (Drawn from 9 geographically dispersed academic medical centers, bed size from 616 to 692, average # of beds = 660; when applicable, adjusted for 620 bed institution) • B - Annual Salary from: 2003 Case Management Salary Survey Results. Published in: Advance for Providers of Post-Acute Care; May/June 2003, 51-54. • C - University of Missouri Health Care, University Hospital; January through December 2004. (Identified at group request by the UMHC Office of Clinical Effectiveness; when applicable, adjusted for 620 bed institution) • D - Medicare Fee Schedule – 2004 (Intubation – Endotracheal Emergency – Code 31500)
    • 64. AGHAGH Acknowledgments • Kristofer Hagglund, PhD. Dean of Health Policy. School of Health Professions. University of Missouri-Columbia. • Kathryn Nelson, MHA. Patient Safety Officer. Office of Clinical Effectiveness. University of Missouri-Columbia Hospital. • Betty Nikodim. Senior Analyst. Office of Clinical Effectiveness. University of Missouri-Columbia Hospital. • Tim Anderson, RN. Patient Safety Manager. Harry S. Truman Memorial Veterans Hospital. Columbia, MO. • Barb Aston, MSW. Social Worker (Retired). Mid-Missouri Mental Health Center. • Kathryn Burks, RN, PhD. Faculty Advisor. University of Missouri-Columbia Sinclair School of Nursing. • Charles Brooks, MD, FACP. Residency Director. Department of Internal Medicine. UMC School of Medicine. • Rachel Haverstick, MA. Executive Staff Assistant. Center for Health Care Quality. University of Missouri-Columbia.
    • 65. AGHAGH Acknowledgments • Laurel Despins, MS, APRN, BC, CCRN. Project Director. Office of Clinical Effectiveness. Clinical Nurse Specialist, Medical- Neurosurgical ICU. University of Missouri-Columbia. • Mark Kruse. Medical Records. Harry S. Truman Memorial Veterans Hospital. Columbia, MO. • Rebecca Wirth, MSW. Social Worker. Harry S. Truman Memorial Veterans Hospital. Columbia, MO. • Deborah Hurley. Human Resource Associate. Department of Health Management and Informatics. UMC School of Medicine. • Jane Bostick, RN, PhD. Faculty Advisor. UMC Sinclair School of Nursing. • Linda Headrick, MD. Sr. Associate Dean for Education. University of Missouri-Columbia School of Medicine.
    • 66. AGHAGH Contact Information • Presenter Contact information: – Ashley Mahon: aem7ee@mizzou.edu – Russell McCulloh: rjm42b@mizzou.edu – Kevin Norris: kdn337@mizzou.edu – Brian Stout: bjs13e@mizzou.edu • UMC CLARION group was coordinated through the University of Missouri-Columbia Center for Health Care Quality (CHCQ) – For more information, please contact: Rachel Haverstick, Executive Staff Assistant. UMC Center for Health Care Quality Medical Sciences Building, MA128 University of Missouri-Columbia. Columbia, MO 65211 Voice: (573) 882-8905 Fax: [573] 884-0474 Email: haverstickr@missouri.edu.

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