R E V I E W S & A N A LY S E S Missed Respiratory Therapy Treatments: Underlying Causes and Management Strategies Susan C. Wallace, MPH, CPHRM INTRODUCTION Patient Safety Analyst Respiratory care helps provide relief for patients who have difficulty breathing or Lea Anne Gardner, PhD, RN cannot breathe on their own.1-2 Treatments that are not given may adversely affect a Senior Patient Safety Analyst Pennsylvania Patient Safety Authority patient’s respiratory health, safety, and outcome.3 Treatment delays could reduce the Christine Roper, MSN, RN effectiveness of medications and lead to clinical deterioration.3 Stoller et al. estimate Clinical Documentation Improvement Specialist that 3.5% of ordered respiratory treatments are missed.4 Stacked treatment (e.g., giving The Children’s Hospital of Philadelphia treatments to multiple patients concurrently) can interfere with monitoring patients as they receive treatments, which could contribute to an adverse side effect.3,5 ABSTRACT Missed respiratory treatments have been reported to the Pennsylvania Patient Safety For patients who suffer from respira- Authority through its Pennsylvania Safety Reporting System (PA-PSRS). Patients in tory ailments, a missed treatment may Pennsylvania who have missed ordered inhalation treatments have experienced acute exacerbate an existing condition and respiratory failure. One patient who did not receive therapy as ordered said he felt like contribute to the patient requiring a he was jogging all day.* higher level of care. Respiratory therapy In their analysis of events reported through PA-PSRS, Authority analysts noted several is ordered for reasons including treat- event types involving workflow breakdowns that resulted in missed respiratory treat- ment of chronic obstructive pulmonary ments. No reason was provided in almost a quarter of the event reports. disease or cystic fibrosis; treatment of A literature query revealed an apparent scarcity of published research on this topic. an acute illness such as pneumonia Analysts contacted the Pennsylvania Society for Respiratory Care (PSRC), whose or bronchiolitis; or for monitoring after members include respiratory therapy administrators and clinicians, and conducted surgery or other procedures. Events sub- interviews of other respiratory leaders in Pennsylvania to gain perspective. Analysts mitted to the Pennsylvania Patient Safety determined that a survey of Pennsylvania respiratory therapists could offer further Reporting System identified 8,745 insights into the PA-PSRS event reports. missed respiratory treatments reported over a 5-year period; 22.8% of the METHODS event reports did not provide a reason. Respiratory therapists in Pennsylvania Analysts queried the PA-PSRS database to identify (1) missed respiratory treatment and were surveyed to determine the most (2) medication dose omission error events that occurred from January 2010 through common factors contributing to missed December 2014. For the medication dose omission error event narrative, an additional respiratory treatments. Survey analy- filter was applied to identify reports that contained at least one of the following respira- sis revealed treatments were missed tory medications: due to patient unavailability because — Beta2 adrenergic agonists: albuterol (i.e., Ventolin, Proventil, Accuneb, Proair), of other therapies or tests; patient levalbuterol (i.e., Xopenex) refused treatments; or the respiratory — Anticholinergic: ipratropium therapist was unavailable because of — Anticholinergic combination/beta2 adrenergic agonist: ipratropium/albuterol an emergency situation or increased (i.e., Duoneb, Combivent) workload. Strategies to address missed respiratory treatments include coordi- — Anticholinergic inhaler: tiotropium (i.e., Spiriva) nating care using the electronic health — Corticosteroid/beta2 adrenergic agonist long-acting combination inhalers: record and team management, taking budesonide/formoterol (i.e., Symbicort), fluticasone/salmeterol (i.e., Advair) time to explain treatments to patients, The Authority and PSRC developed a survey to determine the most common factors and using assessment protocols to contributing to missed respiratory treatments, from the perspective of Pennsylvania help define treatment frequency and respiratory therapists. The 11 survey questions, available exclusively online with this modality. (Pa Patient Saf Advis 2016 article, were based on the PA-PSRS event report analysis, a literature search, and con- Mar;13[1]:11-17.) versations with hospital-based respiratory managers. Two themes in the PA-PSRS event reports are not included in the survey results: the “Other” category and no identifiable Corresponding Author reason. The survey questions also referenced a 3.5% benchmark for missed respiratory Susan C. Wallace treatments based on the study published by Stoller et al.4 * The details of the PA-PSRS event narratives in this article have been modified to preserve confi- dentiality. None of these event narratives came from facilities interviewed for this article. Vol. 13, No. 1—March 2016 Pennsylvania Patient Safety Advisory Page 11 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S The PSRC distributed the survey to 6,976 Figure 1. Number of Missed Respiratory Treatments Reported to the Pennsylvania member e-mail addresses on November Patient Safety Authority, 2010 through 2014, N = 8,745 18, 2015. The respondents had until NUMBER OF MISSED RESPIRATORY TREATMENTS REPORTED November 25, 2015, to answer the questions. Survey questions were not 2,500 mandatory. Surveys from respondents 2,156 that answered 60% or more of the nine 2,000 1,924 1,863 specific reasons for missed treatments were included. All other survey responses were excluded. 1,500 1,182 RESULTS 1,000 PA-PSRS Event Report 563 Demographics 500 357 Analysts identified 8,745 event reports. 222 175 178 125 Patients age 61 through 90 were affected 0 in the majority of the reported missed r 10 20 30 40 50 60 70 80 90 de respiratory treatments (68.0%, n = 5,943 ol to to to to to to to to to d rn 11 21 31 41 51 61 71 81 of 8,745). See Figure 1. an bo MS16101 91 ew All events occurred in a hospital. Only PATIENT AGE IN YEARS N three event reports were reported as Serious Events, with harm scores E and F; 86.7% (n = 7,579 of 8,745) were patient availability; patients were not in 2 or more times a week. The next most reported with a harm score C (i.e., an their rooms and unavailable when the frequent response was once a day (24.1%, event reached the patient but did not therapist arrived to provide treatment n = 85), followed by once a week (19.8%, cause harm and did not require increased (15.9%, n = 1,389 of 8,745). Close to one n = 70), and more than once a day (18.4%, monitoring) and 9.7% (n = 850) were quarter of the reports (22.8%; n = 1,998) n = 65). Respondents were also asked reported with a harm score A (i.e., unsafe provided no specific reason for the missed how often respiratory treatments were conditions, circumstances that could treatment. “stacked” (see Table 2). cause adverse events). The Pennsylvania Figure 2 compares event reports from Patient Safety Authority Harm Score Survey Results PA-PSRS to survey results. About 43.3% Taxonomy is available at http:// The survey was emailed to 6,976 respi- (n = 153) of respondents indicated that an patientsafetyauthority.org/ADVISORIES/ ratory therapists who returned 353 emergency coverage policy was in place, AdvisoryLibrary/2015/mar;12(1)/ surveys that met the inclusion criteria, of which 61.4% (n = 94 of 153) indicated PublishingImages/taxonomy.pdf. for a 5.1% response rate (see Table 1 for that the policy did not limit the number demographics). of missed treatments, 22.9% (n = 35) Reasons for Missed Treatments More than half of respondents (52.4%, did not know whether the policy limited Analysts grouped events into 11 different n = 185 of 353) were unaware of the per- missed treatments, and 15.7% (n = 24) themes based on event report narrative centage of missed treatments per month in said their policy did limit missed treat- descriptions (Figure 2). their facilities, 30.3% (n = 107) indicated ments. When asked if there was a policy 3.5% or fewer respiratory treatments for non-respiratory therapists (e.g., regis- The two most frequently reported rea- were missed per month, and 17.3% tered nurses) to administer treatments, sons for missed treatments were related (n = 61) indicated more than 3.5% of 57.5% (n = 202 of 351) indicated no, to therapist availability: therapist not respiratory treatments were missed per 27.9% (n = 98) indicated yes, and 14.5% available (i.e. variation in demand, staff month. When asked about how often a (n = 51) did not know. unavailable; 20.0%, n = 1,754 of 8,745) and therapist called away emergently respiratory therapist missed one or more (18.3%, n = 1,596). The next most fre- treatments during a typical shift, 37.7% quently reported reason was related to (n = 133 of 353) of respondents indicated Page 12 Pennsylvania Patient Safety Advisory Vol. 13, No. 1—March 2016 ©2016 Pennsylvania Patient Safety Authority Figure 2. Reasons for Missed Respiratory Treatments 1,754 Respiratory therapist not available 2.9 (includes inadequate staffing) 1,596 Respiratory therapist called 3.0 away emergently 1,389 Patient not in room and not available 3.3 Communication issue among 861 providers (includes no order and 2.3 wrong order) 719 Medication not available 2.2 180 Patient unable to participate or 2.4 tolerate treatment 106 Other N/A 94 Patient in room but not available 2.9 35 Patient refused treatment 3.2 33 Equipment not available 1.5 or malfunctions 1,998 No identifiable reason provided N/A 2,000 1,500 1,000 500 0 1 2 3 4 5 TOTAL EVENTS WEIGHTED RANKING Pennsylvania Patient Safety Reporting System Events 2010 through 2014 (N = 8,745) MS16102 Pennsylvania Respiratory Therapist Survey November 2015 (N=353) Types of Respiratory Therapy Found patient’s [respiratory medicine] CPAP was running. Patient became Events in med room, but there was no record less responsive during the afternoon; The following are six deidentified exam- of the patient getting [the respiratory rapid response called and patient sent ples of events reported to the Authority medication]. Went to administer to ICU. involving missed respiratory treatments: medication to patient, but found Patient refused four aerosol patient unresponsive. Airway emer- treatments. I found the patient dia- Respiratory treatment was not admin- gency called and patient transferred istered by respiratory therapy. Patient phoretic, tachypneic with very little to medical intensive care unit (ICU). air movement, and complaining of short of breath; pulse oximeter is 85% on room air. Patient was placed Patient was ordered bilevel positive trouble breathing. on non-rebreather. Patient’s clinical airway pressure (BIPAP)/continuous After lunch, patient complained of condition deteriorated and a rapid positive airway pressure (CPAP). chest pain and shortness of breath. response was called. [Several hours later,] no BIPAP or Patient stated that she did not have Vol. 13, No. 1—March 2016 Pennsylvania Patient Safety Advisory Page 13 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table 1. Survey Respondent Demographics (N = 353) A variety of factors contribute to the CATEGORIZATION RESPONSES PERCENTAGE complex problem of missed respiratory treatments,1-2 such as staffing adequacy, ROLE variation in demand, promotion of team- Staff respiratory therapists 267 75.6% work by organizational culture, patient Respiratory managers/directors 57 16.2% education, and protocols for benchmark- Other roles (e.g., clinical coordinator, 17 4.8% ing and assessing patients.5,7-8 respiratory clinical specialist) Respiratory supervisors 12 3.4% Missed Treatment Studies Two studies found in the literature Total 353 100% address missed respiratory treatments. FACILITY TYPE Researchers at the Cleveland Clinic Acute care hospital, 300+ beds 103 29.2% Hospital (Cleveland, OH) identified the Acute care hospital, 101 to 200 beds 78 22.1% patient’s absence from the room at the time of the therapist’s visit as the most Acute care hospital, 201 to 300 beds 72 20.4% common reason, followed by the patient Acute care hospital ≤100 beds 42 11.9% refusing treatment and the patient being Long-term acute care hospital 20 5.7% unavailable because of ongoing activities or therapy such as physical therapy.4 Rehabilitation hospital 17 4.8% Children’s hospital 10 2.8% A study at Barnes-Jewish Hospital (St. Louis, MO) looked at missed medication Critical access hospital 7 2.0% doses, separated into two categories: oper- Long-term care/group home 4 1.1% ational and non-operational. Operational Total 353 100% missed doses were missed because of situations that could be controlled by FULL-TIME EQUIVALENT (FTE) EMPLOYEES IN THE RESPIRATORY DEPARTMENT respiratory care, such as limited staffing 40 or more 92 26.1% and lack of medication availability. Non- 31 to 40 29 8.2% operational doses that were missed were 21 to 30 53 15.0% because of situations beyond the control of respiratory care, such as the patient 11 to 20 98 27.8% not being available, patient refusing 1 to 10 78 22.1% treatment, or the physician advised not Unknown 3 0.8% to administer. The study revealed missed- Total 353 100% dose rates of 1.1% for operational and 4.5% for non-operational causes.9 a breathing treatment for the past DISCUSSION Common Themes 24 hours. Patient was given a breath- The role of the respiratory therapist has Common themes that emerged from ing treatment. grown more complex over the years. statewide survey responses did not fully Patient did not receive his inhalation Respiratory therapists help patients by align with analysis of the event reports. treatments as ordered. He experienced administering medications during respi- Patient refusal of treatment was a promi- acute respiratory failure, required ratory treatments, communicating with nent theme in the survey but not in event intubation, and was transferred to the the patient, providing education about reports (see Figure 2). The following critical care unit. Investigation of the treatments and therapies, checking oxygen themes are the four most frequently workflow revealed a breakdown in com- saturation levels, measuring pulmonary identified reasons for missed respiratory munication causing missed treatments. function, monitoring and managing ther- treatments identified in the survey, pre- apy, and providing life support and other sented in descending order of frequency. critical care in emergencies.6 Page 14 Pennsylvania Patient Safety Advisory Vol. 13, No. 1—March 2016 ©2016 Pennsylvania Patient Safety Authority Table 2. Survey Respondents: Delivery of Stacked Respiratory Treatments (N = 353) therapists perform for a procedure, which CATEGORIZATION RESPONSES PERCENTAGE then determines appropriate staffing, he said. “Using unweighted metrics such as Very often (more than once a day) 177 50.1% patient days does not give an accurate Often (once a day) 40 11.3% assessment of staffing needs,” he said.12 Sometimes (2 or more times a week) 48 13.6% The AARC guidelines also allow time Rarely (once a week) 31 8.9% for the therapist to provide direct over- Never 57 16.1% sight of care one patient at a time. The AARC states that concurrent therapy Total 353 100% or “stacking” treatments leads to report- ing erroneously high productivity values Patient not in room and not available. Hospital, Reading Health System.12 “The and potentially places the patient at risk Respiratory therapists usually travel to the therapist is an advocate for patients’ because therapists cannot directly monitor patient’s room to administer treatments safety,” Cash said. “The therapist has to the patient throughout the treatment.5,13 in a scheduled timeframe. However, the take the time to explain the consequences However, the survey responses of PSRC timing of respiratory and other treat- of going without treatment and not just members show that this practice is com- ments are not always coordinated among walk away.”12 mon among respondents, with 75% of caregivers.10 them indicating they perform concurrent Respiratory therapist called away emer- therapy at least one or more times a week. “The patient may not be available gently. Therapists are faced with many for a multitude of reasons,” said responsibilities during their shifts that The role of the reporter may influence Thomas Lamphere, BS, RRT-ACCS, are challenged when emergencies occur. both what is observed and what is under- RPFT, FAARC, executive director of The therapist administers treatments stood about the incidence and causes of PSRC. “They may be receiving nursing during a shift, usually guided by a work- missed treatments; the role of the reporter care, their dinner just delivered, or they sheet or schedule. If a rapid response is generally not available in PA-PSRS may be out of the room getting a CT or a cardiac arrest occurs, the therapist reports. Other studies have reported vary- [computed tomography] scan. The thera- assigned to attend the emergent situa- ing numbers and types of event reports pist may make three separate attempts to tion has to deviate from the schedule.10 obtained by using different methods of administer treatments but is not always “Emergencies happen in healthcare,” reporting or investigation.14 Facilities may successful.”10 Lamphere said. ‘The best way to handle consider evaluating information from these situations is for the therapists to both PA-PSRS reports and the survey to Patient refused treatment. Non-adherence work as a team. But sometimes despite provide a more complete analysis. can occur when patients’ treatment plans are too complex, they feel well at the good teamwork, you may still not have time the intervention is offered, they lack enough staffing. Supervisors may help. Limitations understanding about the importance of Other therapists can kick in and help. Several of the PA-PSRS event descriptions the treatment, or the treatment may be Every hospital differs in how they handle could not be categorized because they scheduled at inconvenient times (e.g., in these situations.”10 contained limited information such as the middle of the night).11 Patients have “respiratory treatment missed” and did Respiratory therapist not available. the right to refuse treatment and do not not offer additional insights into why the Respiratory managers, and other profes- always feel there is a need for a respiratory treatment was missed. The low response sional services, have experienced the treatment, Lamphere said. “Patients feel rate for the survey may be the result of problems and frustration of workload they are breathing fine, so they believe a one-week completion date with no increases, according to Cash. Cash uses they do not need treatment,” he said.10 reminder. Events resulting in harm may a statistically valid activity time standard not have been reported as an outcome of A key factor in patient refusal is whether defined by the American Association for a missed treatment. patients were given enough informa- Respiratory Care (AARC) for respiratory tion to make an informed decision, said services to determine staffing levels. The Lester Cash, MBA, BSM, RRT, Division time standards take into account all clini- Director Respiratory Care, Reading cal and support activities that respiratory Vol. 13, No. 1—March 2016 Pennsylvania Patient Safety Advisory Page 15 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S RISK REDUCTION STRATEGIES Rounding. Include respiratory therapists Productivity and Staffing The following risk-reduction strategy sug- in patient rounds with physicians, case Triage. Use a triage system to reassign gestions address the four most common managers, and nurses to discuss patient patient-care needs when therapists are reasons for missed respiratory treatments care and discharge disposition. Rounding unable to accomplish duties. For example, identified from the survey results and as a team helps to coordinate care in a a respiratory therapist could contact a are based on recommendations found in timely manner.10,21 shift charge therapist to communicate the literature, AARC best practices, and Interdisciplinary Coordination potential missed therapy, which could expert opinions of practicing respiratory then be reassigned.9 Check electronic health records (EHRs). If therapists. “Surge” position. Consider establishing the hospital’s EHR has the ability to pro- vide patient locations, identify a computer a “surge” position. This position could Appropriateness of Care terminal where respiratory therapists can be an unassigned therapist who assists Assessment protocols. Use assessment and check patients’ location when patients are with unscheduled activity such as patient treatment protocols that allow respiratory not in their rooms.12 emergencies, as well as scheduled therapy therapists to evaluate patients, interact during peak administration times.9 White boards. Use patient whiteboards with physicians to minimize unnecessary Partner for the day.Plan for shift partners hung in the patient’s room to communi- care, and optimize care ordered by the who can help relieve duties between respi- cate what and when tests or treatments physician.8 Initiate or modify a patient’s ratory therapists when days become busy.12 are scheduled for the patient on a given care plan following the set of physician day. Whiteboards improve teamwork, orders, including instructions or interven- communication, and patient care.22 CONCLUSION tions that the respiratory therapist can adjust as the patient’s medical condition Interdisciplinary teamwork. Develop PA-PSRS reports and a statewide sur- dictates. Protocols are generally written in other communication systems, such as a vey of respiratory therapists provided a algorithmic form, are based on scientific communication wheel that can be dialed foundation to understand why missed evidence, and include guidelines and to indicate when the patient will return to respiratory treatments occur. Reasons for options at decision points along with the room.23 missed treatments in the two data sources clearly stated outcome objectives.15-17 were similar, with the exception that the Patient Education survey of respiratory therapists suggested Track missed treatments. Track reasons Explain treatment. Ensure that patients a greater incidence of patient refusal for missed treatments to gain a better are involved in the treatment plan when of treatment. Tracking the reasons for understanding of why they occur. Review possible and understand the rationale missed treatments is the first step to better information with staff and patient safety behind the medication, the side effects, understand facility-based trends and may committee or management team, and post and dosing frequency.24 guide managers as they consider methods statistics in an easy-to-read area such as a Listen to the patient. Listen to the to coordinate care and develop time- break room.12 patient’s perspective and concerns.24 driven standards. Further studies of this Benchmarking. Consider participating in topic, including the clinical consequence the AARC benchmarking website (http:// Mode of delivery. Consider working with of missed therapies, may help to guide www.aarc.org/resources/tools-software/ the patient and physician to change the further interventions. benchmarking) to exchange informa- mode of delivery to make it easier and tion and identify best practices.18-20 The quicker for the patient. For example, the Acknowledgment site allows hospitals to provide accurate patient may prefer inhaler use rather than Stephanie Uses, PharmD, MJ, JD, Patient Safety a nebulizer treatment.10 Analyst, ECRI Institute, provided pharmacologic data to support administrative staffing expertise. decisions, identify and promote best pro- fessional practices, and define comparison groups.18 Page 16 Pennsylvania Patient Safety Advisory Vol. 13, No. 1—March 2016 ©2016 Pennsylvania Patient Safety Authority NOTES 1. Spader C. Breathing treatments. 2013 Jul 8. Shelledy DC, LeGrand TS, Peters JI. An 17. Kollef MH, Shapiro SD, Clinkscale D, 7 [online]. [cited 2015 Dec 1] http://www. assessment of the appropriateness of respi- et al. The effect of respiratory therapist- healthgrades.com/procedures/breathing- ratory care delivered at a 450-bed acute initiated treatment protocols on patient treatments care veteran’s affairs hospital. Respir Care outcomes and resource utilization. Chest 2. American Association for Respiratory 2004 Aug;49(8):907-16. 2000 Feb;117(2):467-75. Care. Position statement: definition 9. Clayton, D. Missed respiratory 18. American Association for Respiratory of respiratory care. Revised 2015 Jul. medication: impact and potential. Care. AARC benchmarking system. [online]. [cited 2015 Dec 9] http:// 2009 Jun 29. [online]. [cited 2015 [online]. [cited 2015 Dec 10] http:// www.aarc.org/app/uploads/2014/10/ Dec 6]. http://respiratory-care-sleep- www.aarc.org/resources/tools-software/ definition_of_respiratory_care.pdf medicine.advanceweb.com/article/ benchmarking/ 3. Spandorfer MA, Piening J, Darby missed-respiratory-medication-impact-and- 19. Chatburn R. The AARC bench- JL, et al. Aerosol medication sched- potential.aspx marking project part 1: overview. uled delivery errors on hospitalized 10. Lamphere, Thomas (Executive Director, AARC Times 2006 Jun:26-8. https:// patients. The International Respira- Pennsylvania Society for Respiratory www.respiratorybenchmarking.org/ tory Convention & Exhibition. AARC Care). Conversation with: Pennsylvania resources%5CAARC%20Times-June%20 Congress 2010. 1149848 Respir Care Oct Patient Safety Authority. 2015 Aug 28. 06-Benchmarking%20Project-an%20 2011;56(10):1698. http://rc.rcjournal. 11. Jimmy B, Jose J. Patient medication adher- Overview-Chatburn.pdf com/site/open_forum/2011_OF.pdf ence: measures in daily practice. Oman 20. American Association for Respiratory 4. Stoller JK, Orens DK, Kester L. Missed Med J 2011;26(3):155-9. [online]. [cited Care. Uniform reporting manual. 2012 bronchodilator medication treatments 2015 Dec 14]. http://www.ncbi.nlm.nih. [online]. [cited 2016 Feb 12] http:// in respiratory therapy: frequency and gov/pmc/articles/PMC3191684/ www.aarc.org/resources/tools-software/ underlying causes. Respir Care 2003 12. Cash, Lester (Division Director, Respira- standards-development/ Feb;48(2):110-4. tory Care, EEG, Sleep Disorders, Geriatric 21. Paules, Mark (Manager, Respiratory Care 5. American Association for Respiratory Center, Pulmonary Medicine Services, Services, Grand View Hospital). Conver- Care. White paper: best practices in respi- Palliative Care Services, Rheumatology sation with Pennsylvania Patient Safety ratory care productivity and staffing 2012 Services, Reading Hospital, Reading Authority. 2015 Oct 29, 2015 Dec 8. Nov 8. [online]. [cited 2015 Dec 9] http:// Health System). Conversation with 22. Sehgal NL, Green A, Vidyarthi AR, et al. www.aarc.org//app/uploads/2013/07/ Pennsylvania Patient Safety Authority. Patient whiteboards as a communication productivity_and_staffing.pdf 2015 Oct 28. tool in the hospital setting: a survey of 6. American Association for Respiratory 13. HCPro. Use concurrent respiratory practices and recommendations. J Hosp Care. The history of respiratory therapy. therapy as a last resort. 2004 Jan 25;2(4). Med 2010 Apr;5(4):234-9. [online]. [cited 2015 Dec 14] http://www. 14. Westbrook JI, Ling L, Lehnbom EC, et al. 23. Hefner J, McAlerney AS, Mansfield J, aarc.org/aarc/timeline-history/ What are incident reports telling us? Int J et al. A falls wheel in a large academic 7. Giordano SP. Observations: documenting Qual Health Care. 2015 Jan 15;27(1):1-9. medical center: an intervention to reduce efficiency. AARC Times 2006 May:34-5. 15. Modrykamien AM, Stoller JK. The scien- patient falls with harm. J Healthc Qual [online]. [cited 2015 Dec 14] https:// tific basis for protocol-directed respiratory 37(6):374-80. www.respiratorybenchmarking.org/ care. Respir Care 2013 Oct;58(10):1662-8. 24. American College of Preventative resources%5CAARCTimes-05-06%20 Medicine. Medication adherence time 16. American Association for Respiratory Documenting%20Efficiency%20 tool: improving health outcomes. 2011. Care. Position statement: respiratory Giordano.pdf [online]. [cited 2015 Dec 10] http://www. therapy protocols. Revised 2013 Apr. [online]. [cited 2015 Dec 9] http:// acpm.org/?MedAdherTT_ClinRef c.aarc.org/resources/position_statements/ documents/respiratory_therapy_ protocols2013.pdf Vol. 13, No. 1—March 2016 Pennsylvania Patient Safety Advisory Page 17 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 1—March 2016. 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