R E V I E W S & A N A LY S E S Tracking Ambulatory Surgical Facility Cancellations and Transfers: Lessons Learned from an 18-Month Collaboration Lea Anne Gardner, PhD, RN INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority Cancellations and transfers are ongoing problems that ambulatory surgical facilities (ASFs) have identified, and when examined, these problems have revealed patient safety concerns.1 Starting in 2012, the Pennsylvania Patient Safety Authority worked ABSTRACT in collaboration with 11 ASFs in the northeast region of Pennsylvania to standardize In 2012, 11 ambulatory surgical facili- the nurse-driven preoperative screening and assessment process in an effort to reduce ties (ASFs) in the northeast region of day-of-surgery (DOS) cancellations and transfers. DOS cancellations represent oppor- Pennsylvania worked in collaboration tunities to identify and address patient safety concerns and improve patient care by with the Pennsylvania Patient Safety identifying medical conditions or situations (e.g., patients failing to meet screening Authority to address the nurse-driven criteria, patients not following preoperative instructions) that place patients at risk for preoperative screening and assess- harm if they have surgery or a procedure. ment process in an effort to reduce When DOS cancellations occur, communication is necessary between the surgeon and day-of-surgery (DOS) cancellations and surgical team, often while in the midst of other procedures, to rearrange the surgical transfers. The ASFs tracked the time schedule for the rest of the day. 2 This type of disruption, referred to as a case-irrelevant when the nurse-driven preoperative communication, has the potential to distract the team and lead to adverse events.2,3 screening and assessment process was Reducing DOS cancellations reduces distractions and preserves schedule continuity and completed (e.g., 24 hours prior to the staff attention toward patients currently receiving care, thereby improving patient safety. DOS). A statistically significant differ- ence was noted between no-show DOS During the 18-month ASF Preoperative Screening Collaboration, the implementation cancellation rates in patients with and of three interventions resulted in reductions in DOS cancellations and transfers. The patients without a preoperative screen- three interventions involved use of a standardized preoperative screening tool to stan- ing and assessment. Reasons for DOS dardize the nurse-driven preoperative screening and assessment process, institution of cancellations and transfers and types health literacy strategies into written materials and oral conversations with patients, of surgeries or procedures were also and completion of an additional preoperative phone call to supplement the initial pre- tracked. To continue the identification operative screening contact. The majority of the nurse-driven preoperative screenings of DOS cancellations and transfers, and assessments were conducted over the phone, and the remainder in person. the ASF Cancellation and Transfer Analysis of collaboration data identified a statistically significant difference between Tracking tool was developed to identify DOS no-show cancellation rates in patients who had and patients who did not have a trends regarding when a nurse-driven nurse-driven preoperative screening and assessment. The initiation of health literacy preoperative screening and assessment strategies and completion of an additional phone call also led to reductions in DOS process has been completed, reasons cancellations.1 An important lesson learned from this collaboration was that tracking for DOS cancellations or transfers, types DOS cancellations and transfers helps identify opportunities to improve an ASF nurse- of surgeries or procedures in patients driven preoperative screening and assessment process. The introduction of a new ASF who cancelled or were transferred, and tracking tool that monitors the nurse-driven preoperative screening processes, DOS patient characteristics associated with cancellation and transfer event information and rates, and DOS cancellation costs patient transfers. Identifying reasons for in real-time provides ASFs a timely way to identify trends. Collecting and trending patient cancellations and transfers to detailed information about DOS cancellations and transfers provides opportunities an acute care hospital provides context to learn about the circumstances surrounding these events and to gain new insights to about patient circumstances or situa- increase the likelihood of averting similar events in the future. tions that can assist healthcare staff in developing appropriate solutions to METHODS reduce their occurrence and improve patient care. (Pa Patient Saf Advis 2014 Tracking Tool Sep;11[3]:109-14.) The Authority developed the ASF Cancellation and Transfer Tracking tool to assist ASFs with tracking and trending DOS cancellation and transfer rates, as well as event Scan this code with your mobile information and costs associated with DOS cancellations. The tracking tool provides device’s QR structured data entry that links to automated, real-time reports along with free-text reader to access fields for individualized notes. This tool collects data for a 12-month period that is the Authority's determined by the ASF. When developing the tracking tool, consideration was given toolkit on this to the facilities’ scopes of care: general surgical or specialty services. Rather than topic. Vol. 11, No. 3—September 2014 Pennsylvania Patient Safety Advisory Page 109 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S developing one tracking tool with a broad were amenable to the nurse-driven preop- and the type of surgery or procedure range of surgical and procedural choices erative screening and assessment processes. that is cancelled. It is important to track that might not be applicable to a specialty For example, surgeon illness, severe the time that the preoperative screening ASF, three separate tracking tools were weather conditions, and family emergen- process is completed, especially given the developed: one for general surgical ASFs, cies are situations that are unpredictable finding of a statistically significant dif- one for endoscopic ASFs, and one for oph- and at times arise without ample notice ference in no-show cancellations noted thalmologic ASFs. to reschedule patients. Completing a for patients with versus patients without nurse-driven preoperative screening and a preoperative screening and assess- DOS Cancellations assessment had limited impact in reducing ment.1 There are six different choices to A DOS cancellation is defined as a cancella- DOS cancellations due to these reasons. indicate the time when a nurse-driven tion of a scheduled surgery or procedure for Cancellation reasons deemed amenable preoperative screening and assessment is any reason that occurred after 12:01 a.m. to the nurse-driven preoperative screening completed: on the DOS, whether the cancellation and assessment processes are included in 1.DOS occurred prior to admission, after admis- the tracking tool. The seven DOS cancel- 2. 24 hours prior to the DOS sion, or after anesthesia. Cancellation lation reasons selected for inclusion in the 3. 48 hours prior to the DOS rates for three time periods were tracked tracking tool are based on whether the during the collaboration and are tracked 4. Greater than 48 hours prior to the nursing-based interventions implemented in the ASF tracking tool using the same DOS in the collaboration had the potential to time frames: DOS cancellations, 24-hour influence reductions in DOS cancella- 5. Screening not completed cancellations,* and 48-hour cancellations.† tions. See Table 2 for descriptions of the 6. ASF unable to contact the patient— Cancellation rates in the tracking tool are seven reasons for cancellation included in consequently, no nurse-driven calculated and tracked monthly and are the tracking tool. preoperative screening and assess- reported as the number of cancellations ment was completed The tracking tool also includes data per 1,000 completed procedures. Tracking the types of surgeries and proce- fields for the time when the preoperative Two pieces of data are required for the screening and assessment is completed dures cancelled during the collaboration tool to calculate a cancellation rate: (1) the number of cancellations for each time Table 1. Reasons for Ambulatory Surgical Facility Day-of-Surgery Cancellations from period (i.e., DOS, 24 hours, or 48 hours) December 2012 through June 2013 (N= 824), as Reported by Collaboration Participants in which the cancellation occurred dur- REASON FOR CANCELLATION NO. OF % OF ing a given month and (2) the number of CANCELLATIONS CANCELLATIONS completed procedures for the same given month. The ASF tracking tool calculates Change in medical status* 237 28.8 cancellation rates in real time and pres- No-shows 156 18.9 ents these rates as a trend line. Preoperative instructions not 103 12.5 DOS cancellations are identified and followed grouped according to the underlying Procedure not rescheduled 77 9.3 reason prompting the cancellation. There Rescheduled procedure 52 6.3 were 13 reasons for DOS cancellations Protocol issues 51 6.2 identified during the collaboration (see Table 1). Not all 13 cancellation reasons Weather related* 43 5.2 Financial issues 30 3.6 * A 24-hour cancellation is defined as a cancella- Transportation 20 2.4 tion that occurred 24 hours prior to 12:01 a.m. on the DOS. The collaboration 24-hour cancel- Family issues/emergencies* 19 2.3 lation rate was 27.0 cancellations per 1,000 Surgeon illness* 19 2.3 completed procedures. † A 48-hour cancellation is defined as a cancella- Work related 4 0.5 tion that occurred 48 hours prior to 12:01 a.m. on the DOS. The collaboration 48-hour cancel- Language barrier 2 0.2 lation rate was 11.5 cancellations per 1,000 * These cancellation reasons collected during the collaboration are rarely amenable to a nurse-driven complete procedures. preoperative screening and assessment. Page 110 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority was important to the ASFs to determine endoscopic procedure identified during cancelled during the collaboration if patterns existed in the cancellations. the collaboration. The list of surgeries (e.g., cataracts surgery, plastic surgery, For example, diagnostic colonoscopies and procedures generated for the tracking pain management). were the most frequently cancelled type of tool is based on surgeries and procedures Transfers A transfer is defined as an ASF admis- Table 2. Ambulatory Surgical Facility Tracking Tool Reasons for Cancellations and Descriptions* sion requiring an unexpected hospital REASON DESCRIPTIONS† transfer or admission directly following discharge from the ASF. ASF transfers are Protocol issues Patient did not meet screening criteria a patient safety measure that the Centers (i.e., failure to adhere Medical issues missed during preoperative screening for Medicare and Medicaid Services will to facility protocol) Miscommunication and lack of communication between use for public reporting and payment providers determination for 2014.4,5 Transfer rates Equipment issues (e.g., implant not available, power are calculated in the same manner as can- outages) cellation rates: monthly and reported as Incomplete or missing history and physical the number of transfers per 1,000 admis- Scheduling delay sions. Two pieces of data are required, the number of transfers per month and the Preoperative instructions Nothing-by-mouth or dietary requirements not adhered not followed to number of admissions per month. The ASF tracking tool calculates the transfer Prep issues (e.g., sick from prep, did not complete prep) rate in real time and presents these rates Medication instructions not followed as a trend line. Misunderstanding day or time of procedure Patient transfer event information col- Procedure not No explanation lected in this tracking tool focuses on rescheduled Patient changed his or her mind a broader scope of data than the DOS Mental health or anxiety cancellation event information. The Scheduling conflict basic data requirements for transfer event information are the same as the DOS Patient overslept cancellation event data collection: the Rescheduled procedure No explanation event date, the time the preoperative Scheduling conflict screening and assessment is completed, Communication issues with patient and the surgery or procedure the trans- Financial Insurance and payment-related issues ferred patient is scheduled to undergo or has undergone. Additional transfer data Transportation No ride to or from the ambulatory surgical facility requirements comprise three patient char- Car troubles the day of surgery (e.g., stuck in traffic, acteristics: (1) the patient’s age, physical dead battery)‡ status according to the American Society No-shows§ No explanation of Anesthesiologists’ classification system,6 Patient forgot and body mass index;7 (2) time of the Miscommunication and lack of communication with transfer (preoperative and postoperative); patient and (3) reasons for the transfer (selected Patient wanted second opinion from a 13-item list). * Cancellation reasons not included in the tracking tool are changes in medical status (i.e., patients with new medical conditions, exacerbation of existing conditions, colds, infections, hospitalization, Cost Calculator death, or condition improved and no longer required treatment), surgeon illness, weather related, work The ASFs participating in the collabora- related, and language barrier. † The cancellation descriptions are based on interpretations from the ASF Preoperative Screening tion requested assistance with building Collaboration. a business case to examine the impact of ‡ These cancellation reasons may not be affected by the preoperative screening process. cancellations on an ASF by identifying the § No-show explanations best reflected by another defined category (e.g., financial-related issues, scope of the problem and the associated protocol issues) are assigned to those categories to provide a clearer understanding for the reason for no-show day-of-surgery cancellations. financial costs. To address this request, a Vol. 11, No. 3—September 2014 Pennsylvania Patient Safety Advisory Page 111 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S cancellation cost calculator was developed Table 3. Ambulatory Surgical Facility (ASF) Collaboration Reasons for Transfers, during the collaboration and is included as Reported by Participating ASFs from July 1, 2012, through June 30, 2013 in the ASF tracking tool. PREOPERATIVE TRANSFERS POSTOPERATIVE TRANSFERS Cardiac arrhythmias*,† Cardiac arrhythmias*,† RESULTS Hypertension*,† Anesthesia complications, aspirations, or The tracking tool consists of the cost respiratory monitoring*,† Automatic implantable cardioverter calculator, cancellation and transfer defibrillator (AICD) dead battery* Postoperative diagnostic findings*,† rate reports, and DOS cancellation and Syncope† Nausea or vomiting* transfer event information reports. The ASF Cancellation and Transfer Tracking Tool Bleeding or hemorrhage* Reference User Guide explains the different AICD battery not detecting* facets of the tool. Longer monitoring of the patient† The DOS cancellation rates calculated by Pneumothorax† the tracking tool do not provide bench- Arm weakness† marking data. For comparison purposes, Perforation† the collaboration postintervention DOS Pain† cancellation rate was 26.8 cancellations per Urinary retention† 1,000 completed procedures. During the collaboration, two reasons for DOS cancel- Abscess† lations, changes in the patient’s medical Seizures† condition and no-show cancellations, * Transfers that occurred during the preintervention time period from July 2012 through November 2012 accounted for almost half (47.7%, n = 393 † Transfers that occurred during the postintervention time period from December 2012 through June 2013 of 824) of the DOS cancellations. Even though both reasons for DOS cancellations aggregated (deidentified) and individual three nursing-based interventions were account for such a large portion of the facility data. The reports synthesized and implemented.1 The ASF tracking tool pro- cancellations, no-show cancellations are the communicated trends about cancellation vides opportunities for facilities to initiate only reason included in the tracking tool, rates, transfer rates, and preopera- or continue tracking DOS cancellations given its amenability to the nurse-driven tive screening processes and outcomes and transfers monthly and identify pat- preoperative screening processes.1 data. Tracking and evaluating DOS terns and solutions to reduce these events. The transfer rates calculated by the track- cancellations and transfers during the ing tool do not provide benchmarking collaboration was instrumental in help- DOS Cancellations data. For purposes of comparison, the col- ing ASFs identify areas of a nurse-driven Interpreting the data and identifying laboration postintervention transfer rate preoperative screening and assessment the different motivations behind patient was 1.03 transfers per 1,000 admissions. process requiring improvement.1 cancellations helped to clearly elucidate Table 3 lists the reasons for transferring the underlying reasons for these events. As the ASFs implemented the interven- patients to an acute care hospital, identi- DOS cancellation reasons included in the tions for the collaboration, they had fied by the patient’s operative status (i.e., tracking tool were selected on the basis of opportunities to evaluate changes in their preoperative and postoperative). how amenable they were to a nurse-driven processes and any changes in the num- There is no benchmarking data for the ber of DOS cancellations and transfers. preoperative screening and assessment cancellation cost calculator. Each ASF For example, some of the ASFs were process. As noted earlier, cancellations will determine the lost reimbursements able to implement a second preopera- due to a change in the patient’s medical and potential gains according to its own tive phone call that provided additional status, the most frequently reported rea- experience. opportunities for the nursing staff to son for a DOS cancellation, were rarely explore with their patients how well the amenable to a nurse-driven preoperative DISCUSSION patients understood their upcoming sur- screening and assessment process. This Tracking Tool gery or procedure and their preoperative reason for cancellation comprised patients During the collaboration, the events instructions.1 As noted in the March 2014 who presented to the ASF on the DOS the ASFs experienced were shared with Pennsylvania Patient Safety Advisory article, with new undiagnosed medical condi- them via monthly reports that included many other lessons were learned as the tions, exacerbation of existing medical Page 112 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority conditions, cold symptoms, or infections; language barriers), while increases in DOS not identify these types of problems prior patients who were hospitalized or died cancellation rates were observed in the to admission, these transfers represent prior to the DOS; and patients who had remaining four cancellation groups (i.e., safe patient care. The majority of transfers improvements in their medical condition preoperative instructions not followed, reflected issues arising postoperatively. that no longer required treatment. financial issues, procedures not resched- A nurse-driven preoperative screening and uled, and rescheduled procedures). Cost Calculator assessment can have an indirect influence Pattern identification can extend beyond While there are no specific examples of rather than a direct influence on this rea- the list of surgeries or procedures. For ASF use of the cost calculator during the son for cancellation because surgeons and example, if the majority of patients collaboration, it has great potential for anesthesiologists evaluate a patient’s physi- scheduled for a diagnostic colonoscopy ASFs to use as a tool to develop a business cal condition and determine eligibility for cancelled the procedure due to getting case for reducing cancellations. The tool surgery or a procedure on the DOS. One sick from using a particular prep, the staff calculates DOS cancellation rates and lost way nursing staff can influence reductions might alert the physician about the trend reimbursements for the facility and physi- in this reason for cancellation is to stress and have the physician or physician prac- cians and emphasizes opportunities to to patients the importance of calling to tice consider prescribing a different prep. improve reimbursements associated with cancel as soon as they feel ill or notice a reductions in DOS cancellations. The change in their medical condition (e.g., Transfers cost calculator can be used to identify lost hyperglycemia). However, in many cases ASF transfers were a rare event during reimbursements for surgical or procedural experienced during the collaboration, the collaboration. For example, two of DOS cancellations in the aggregate or patients who felt ill or noticed changes in the ASFs had no transfers during both in isolation. their health tended to identify them on the preintervention and postintervention The cost calculator requires the same data the morning of their surgery or procedure. phases of the collaboration. Another ASF to calculate a cancellation rate and facil- There were other instances when issues had two transfers during the preinterven- ity and physician reimbursement data. occurred such as the history and physical tion phase and no transfers during the For example, if an ASF is interested in forms being incomplete or not available postintervention phase. When transfers knowing the lost reimbursements for a at the time of preoperative screening. did occur, differences between the rea- specific type of DOS cancellation, such These types of problems (i.e., protocol sons for preoperative and postoperative as diagnostic colonoscopies, the ASF issues) are much more amenable to a transfers became apparent early in the would identify the total number of diag- nurse-driven preoperative screening and collaboration. The majority of preopera- nostic colonoscopy cancellations and the assessment process. As discoveries about tive transfers in the collaboration resulted expected facility and physician reimburse- the underlying reasons for DOS cancel- from newly discovered medical conditions ments for this procedure. The calculator lations became salient, approaches to not detected during the patient’s preopera- will then calculate the cancellation rate address these issues emerged. tive physical exam (e.g., atrial fibrillation and the total reimbursements lost for the on an electrocardiogram) or exacerbation facility and physician for cancelled diag- Nine of the 13 reasons for cancelling of a preexisting medical condition (e.g., nostic colonoscopies. It will also identify (i.e., transportation issues, protocol hypertension).1 the increased reimbursements associated issues, no-shows, financial issues, pre- Eighty percent of the patients transferred with reductions in diagnostic colonoscopy operative instructions not followed, due to a cardiac arrhythmia preoperatively cancellations. procedures not rescheduled, rescheduled procedures, work issues, and language in the postintervention time period were barriers) were judged to be amenable patients 75 to 85 years old; the remaining Limitations to the interventions introduced during 20% of patients were 65 to 75 years old. The tracking tool collects data on 7 rea- this collaboration. Two of the reasons, Dehydration and being ill on the DOS sons for DOS cancellations and 13 reasons work issues and language barriers, were were additional conditions that may have for transfers. Exclusions of cancellation not included in the tracking tool, since supported the need for a patient transfer.1 reasons in the tracking tool were based these were rare events. Decreases in DOS Cardiac arrhythmia was the only medical on how amenable a cancellation reason cancellation rates were observed between condition that occurred in both preopera- was to a nurse-driven preoperative screen- the preintervention and postintervention tive and postoperative transfers during ing and assessment, use of health literacy period in five of these nine cancellation both preintervention and postinterven- strategies, or completion of an additional groups (i.e., transportation issues, pro- tion time periods. While preoperative preoperative phone call. tocol issues, no-shows, work issues, and screening and assessment processes might Vol. 11, No. 3—September 2014 Pennsylvania Patient Safety Advisory Page 113 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S problems encountered, such as whether ASF CANCELLATION AND TRANSFER TRACKING TOOLS a nurse-driven preoperative screening and assessment process is executed.1 The Pennsylvania Patient Safety Authority developed three ambulatory surgical facility Synthesizing data collected in the tracking (ASF) cancellation and transfer tracking tools, available at http://patientsafetyauthor- tool provides opportunities to identify ity.org/EducationalTools/PatientSafetyTools/asf/Pages/home.aspx, designed for three different types of ASFs: more than just problems or issues with cancellations or transfers. There are 1. The general surgery tracking tool opportunities to use the data to iden- 2. The ophthalmologic tracking tool tify and incorporate enhancements to nurse-driven preoperative screening and 3. The endoscopic tracking tool assessment processes, including the use of health literacy strategies and additional preoperative phone calls. As enhance- ments are implemented, continual Additionally, the tool does not include The lack of benchmarking data poses tracking of these events offers facilities how a nurse-driven preoperative screening another set of challenges for ASFs. Using ongoing feedback to evaluate the value of and assessment is conducted, although the cancellation and transfer rates from changes made to the nurse-driven preop- they are typically conducted by phone. the collaboration provides an initial erative screening and assessment process. Phone interviews lack a visual component. benchmark. Future transfer rate bench- The Authority’s ASF Cancellation and Nonverbal cues from patients during the marks can be obtained quarterly from Transfer Tracking tool offers ASFs the preoperative screening process afford the national Ambulatory Surgery Center opportunity to track cancellation and the nurse insights to identifying patient Quality Collaboration.8 transfer rates, collect event information, behaviors indicative of misinterpretation and evaluate the costs of cancellations. or miscomprehension of preoperative CONCLUSION instructions. The implementation of a Acknowledgments Reducing cancellations and transfers Jeff Bomboy, RN, BS, patient safety liaison; standardized checklist that included sug- starts with collecting and evaluating Megan Shetterly, RN, MS, and Christine Hunt, gested questions to ask patients, along RN, MSN, MBA, HCM, senior patient safety data pertaining to the circumstances with instituting health literacy strategies, liaisons; and Denise Martindell, RN, JD, former surrounding these events. Tracking senior patient safety analyst, worked on this col- helped to overcome some of the challenges components of patient cancellations and laboration as team lead, team members, and when conducting a nurse-driven preopera- former team lead, respectively. transfers in real time provides evidence of tive screening over the phone. NOTES 1. Gardner LA, Bomboy J. Preoperative 4. Centers for Medicare and Medicaid Ser- 7. National Institutes of Health (NIH). screening and the influence on cancel- vices. Ambulatory Surgical Center Quality Clinical guidelines on the identification, lations and transfers: an ambulatory Reporting Program: quality measures evaluation, and treatment of overweight surgical facility collaboration. Pa Patient specifications manual [online]. 2012 Jul and obesity in adults: the evidence report Saf Advis [online] 2014 Mar [cited 2014 [cited 2013 Oct 8]. http://www.asge.org/ [online]. NIH pub. no. 98-4083. 1998 Sep Mar 1]. http://patientsafetyauthority.org/ assets/0/47668/71298/ccb3adeb-9fc4- [cited 2013 Apr 5]. http://www.nhlbi.nih. ADVISORIES/AdvisoryLibrary/2014/ 4a3a-a522-1db072f65ef4.pdf gov/files/docs/guidelines/ob_gdlns.pdf Mar;11(1)/Pages/15.aspx 5. Centers for Medicare and Medicaid 8. ASC Quality Collaboration. ASC Quality 2. Feil M. Distractions in the operating Services. ASC quality reporting [online]. Collaboration quality report: 1st quarter room. Pa Patient Saf Advis [online] 2014 [cited 2013 Oct 8]. http://www.cms. 2014 [online]. 2014 [cited 2014 Jul 3]. http:// Jun [cited 2014 Mar 1]. http://patient gov/Medicare/Quality-Initiatives- www.ascquality.org/qualityreport.cfm safetyauthority.org/ADVISORIES/ Patient-Assessment-Instruments/ AdvisoryLibrary/2014/Jun;11(2)/ ASC-Quality-Reporting/index.html Pages/45.aspx 6. American Society of Anesthesiologists 3. Sevdalis N, Healey AN, Vincent CA. (ASA). ASA physical status classification Distracting communications in the system [online]. [cited 2013 Oct 1]. http:// operating theatre. J Eval Clin Pract 2007 www.asahq.org/Home/For-Members/ Jun;13(3):390-4. Clinical-Information/ASA-Physical-Status- Classification-System Page 114 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 11, No. 3—September 2014. 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