Welcome to the
NQF Safe Practices for Better Healthcare
2009 Update Webinar:
Clear Communication Practices
for Safer Healthcare
(Safe Practices 12-16)
Hosted by NQF and TMIT
Attendee dial-in instructions:
Toll-free Call-in number (US/Canada): 1-866-764-6260
(direct number, no code needed)
To join the online webinar, go to:
www.safetyleaders.org
Online Access Password: Webinar1 (case-sensitive)
Welcome and Safe Practices
Overview
Hayley Burgess, PharmD
Director, Performance Improvement
Measures, Standards, and Practices
TMIT
Toll-free Call-in number: 1-866-764-6260
Safe Practices Webinar
November 19, 2009
2
Panelists
Hayley Burgess
David W. Bates
Kimberly Visconti
Peter Angood
Hayley Burgess:
David W. Bates:
Kimberly Visconti:
Welcome and Safe Practices Overview
Achieving Success with CPOE
Using RED to Implement NQF SP 15:
Discharge
Peter Angood:
Practical Implementation Approaches to Patient
Care Information, Order Read-Back and
Abbreviations, and Labeling of Diagnostic Studies Arlene Salamendra
Arlene Salamendra: Roles for the Patient Advocate (Are You Listening?)
5
Culture
Consent & Disclosure
Consent and Disclosure
Workforce
Information Management and
Continuity of Care
Medication Management
Healthcare-Associated
Infections
Condition- and
Site-Specific Practices
Toll-free Call-in number: 1-866-764-6260
Culture
Structures
and Systems
Culture Meas.,
FB., and Interv.
Team Training
and Team Interv.
ID and Mitigation
Risk and Hazards
CHAPTER 2: Creating and Sustaining a Culture of
Patient Safety (Separated into Practices]
 Leadership Structures and Systems
 Culture Measurement, Feedback, and Interventions
 Teamwork Training and Team Interventions
 Identification and Mitigation of Risks and Hazards
Consent
& Disclosure
Consent
and
Informed
Consent
Life-Sustaining
Treatment
Care of
Caregiver
Disclosure
Workforce
2009
NQF Report
Nursing
Workforce
Direct
Caregivers
CHAPTER 3: Informed Consent and Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
• Care of the Caregiver
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
ICU Care
Legend:
No Material
Changes
Information Management and Continuity of Care
Patient
Care Info.
Material
Changes
Read-Back
& Abbrev.
Labeling
Studies
Discharge
System
CPOE
CHAPTER 5: Information Management and Continuity
of Care
 Patient Care Information
 Order Read-Back and Abbreviations
 Labeling Studies
 Discharge Systems
 Safe Adoption of Integrated Clinical Systems
including CPOE
New
Medication Management
CHAPTER 6: Medication Management
 Medication Reconciliation
 Pharmacist Leadership Role Including: High-Alert
Med. and Unit-Dose Standardized Medication
Labeling and Packaging
Med. Recon.
Pharmacist Systems Leadership:
High-Alert, Std. Labeling/Pkg., and Unit-Dose
Healthcare-Associated Infections
Influenza
Prevention
Hand Hygiene
Sx-Site Inf.
Prevention
VAP
Prevention
Central V. Cath.
BSI Prevention
MDRO
Prevention
UTI
Prevention
Condition-, Site-, and Risk-Specific Practices
Wrong-site
Sx Prevention
Contrast
Media Use
Organ
Donation
Press. Ulcer
Prevention
Glycemic
Control
DVT/VTE
Prevention
Falls
Prevention
Anticoag.
Therapy
Pediatric
Imaging
CHAPTER 7: Hospital-Associated Infections
• Hand Hygiene
• Influenza Prevention
• Central Venous Catheter-Related Blood Stream
Infection Prevention
• Surgical-Site Infection Prevention
• Care of the Ventilated Patient and VAP
• MDRO Prevention
• UTI Prevention
CHAPTER 8:
• Wrong-Site, Wrong-Procedure, Wrong-Person
Surgery Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
• Contrast Media-Induced Renal Failure Prevention
• Organ Donation
• Glycemic Control
• Falls Prevention
• Pediatric Imaging
7
Achieving Success
with Computerized Physician
Order Entry (CPOE)
David W. Bates, MD, MSc
Medical Director of Clinical and Quality Analysis,
Partners Healthcare
Chief, Division of General Internal Medicine
Brigham and Women’s Hospital
Toll-free Call-in number: 1-866-764-6260
Safe Practices Webinar
November 19, 2009
8
Goals
• NQF Safe Practice
• CPOE benefits
- Drugs
- Labs
- Other
• Meaningful use overview
• CPOE risks
- University of Pennsylvania (Koppel)
- University of Pittsburgh (Han)
• Implementing well
• CPOE and the big picture
•
- Bar-coding
Conclusions
9
Safe Practice 16: CPOE 2009
Implement a computerized prescriber
order entry (CPOE) system built upon the
requisite foundation of re-engineered
evidence-based care, an assurance of
healthcare organization staff and
independent practitioner readiness, and
an integrated information technology
infrastructure.
Toll-free Call-in number: 1-866-764-6260
10
CPOE as part of the EHR
• Is centrally important because most things
that occur in a hospital happen as the result
of a physician’s order
- Need to get physician to use the computer
- Key opportunity to change behavior
• Many opportunities to improve performance
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11
Inpatient Prevention
• 55% reduction in serious medication error
rate with CPOE
Bates, JAMA, 1998
• 83% reduction in overall medication error
rate
Bates, JAMIA, 2000
• Cost of each preventable ADE ~ $6,000
Toll-free Call-in number: 1-866-764-6260
12
Systematic Review of Impact of
CPOE on Medication Safety
• 5 trials of CPOE
- 2 marked decrease in serious medication error rate
- 1 improvement in corollary orders
- 1 improvement in 5 prescribing behaviors
- 1 improvement in nephrotoxic drug dose and
frequency
• Numerous additional studies since
Kaushal, Shojania, Bates, Arch Int Med 2003
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13
Other Recent Reviews of CPOE
and Medication Safety
• CPOE and medication errors—66% reduction
in prescribing errors on average
Shamliyan et al., Health Services Res 2008
• CPOE and ADEs—ten studies, five showed
decrease in ADE rates, 4 showed nonsignificant trends, 1 showed no effect
Wolfstadt et al., J Gen Intern Med 2008
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14
Selected Laboratory Interventions
• Charge display RCT
- No statistically significant effect
- BUT $1.7 million lower lab charges in intervention
group
• Redundant labs
- 67% reminders followed
- Annual charge savings $31,000, vs. estimate of
$376,000
- Only 44% tests performed had computer order
- Substantial improvement possible if loop closed with
laboratory “back end”
Toll-free Call-in number: 1-866-764-6260
15
Order Entry and Critical Paths
• Critical paths specify what should happen for
a specific day
- Essentially sequences of order sets
- In place for 25 diagnoses
• Have decreased length of stay, costs,
improved satisfaction
• Require physicians to select diagnosis at
admission
- Allows prompting about path
- Increases likelihood path will be selected
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16
Summary of Benefits
• Benefits are much greater than drug safety
benefits alone
- Those represent small part of financial benefits
• Achieving value depends on building in
good decision support
- Also on ability to modify, iteratively improve
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17
How to Prioritize?
• ROI of inpatient CPOE evaluated
• Cumulative net savings were $16.7 million
over 10 years, and net operating $9.5 million
• Leading contributors
- Renal dosing guidance
- Tools to help nurses
- Specific drug guidance
- Adverse drug event prevention
Kaushal, JAMIA 2006
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18
Meaningful Use is Being Defined
and Will Follow an “Ascension Path”
2009
2011
2013
2015
HIT-Enabled Health Reform
HITECH
Policies
2011
Meaningful
Use Criteria
(Capture/share
data)
2013 Meaningful
Use Criteria
(Advanced care
processes with
decision support)
*Report of sub-committee of Health IT Policy Committee
2015 Meaningful
Use Criteria
(Improved
Outcomes)
19
Meaningful Use Matrix and
Decision Support: Hospitals 2011
• 10% all orders through CPOE
• Drug-drug, drug-allergy, drug-formulary
checks
• Up-to-date problem list
• Generate lists of patients by condition
• Implement one clinical decision rule related
to a high-priority condition
Toll-free Call-in number: 1-866-764-6260
20
Meaningful Use Matrix and
Decision Support: Hospitals 2013
•
•
•
•
Use CPOE for all order types
Use evidence-based order sets
Conduct closed-loop medication management
Use clinical decision support at the point of
care
• Retrieve and act on fill data
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21
University of Pennsylvania:
Unintended Consequences
• Koppel et al. evaluated on a commercial
CPOE application at U Penn and asked users
about their impressions about the system
- Found many situations in which “a leading CPOE
system facilitated medication error risks”
- Often took many screens to do things
- Needed views not available
• Others including Ash have also reported on
this
Toll-free Call-in number: 1-866-764-6260
Koppel, JAMA, 2005
22
Issues with the Koppel Study
• Didn’t actually count errors or adverse events
• Said that other studies focused only on
advantages—not accurate
• CPOE application studied was an old one
• Nonetheless, paper stimulated valuable
debate and identified key points
- Need change systems after implementation
- Software alone is insufficient
Bates, J Biomed Inform, 2005
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23
University of Pittsburgh:
Pediatrics Study
• Studied children transported in for special
care
• Mortality rate increased from 2.8% to 6.3%
(OR=3.3) after introduction of a commercial
CPOE application
• Study design was before-after
- Other changes were made at same time as CPOE was
implemented
- Overall mortality wasn’t reported
Toll-free Call-in number: 1-866-764-6260
Han, Pediatrics 2005
24
Introduction of CPOE
• CPOE was introduced very rapidly—over 6
•
•
•
•
•
days!
After implementation, order entry wasn’t
allowed until the patient had actually entered
hospital and been logged into system
After CPOE implementation, all drugs
including vasoactive agents were moved to
central pharmacy
Pharmacy couldn’t process medication orders
until after they were activated
Many order sets weren’t available initially
Result was substantial delays in care delivery
Comments on Han Study
• Study was very weak methodologically
• Nonetheless, increase in mortality rate was
very large and of obvious concern
- Introducing substantial delays in this group could
easily have caused
• Organization broke many of the rules for
implementation
• Essential for other organizations to handle
sociotechnical aspects better
Phibbs et al., Pediatrics 2005
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26
The Path To Success
in Implementing CPOE
• Much is the inverse of common pitfalls
- But not all
• Anyone will have issues that leadership need
to deal with
• Keep in mind that it will be worth it
- Have to pay attention to details to achieve value—
doesn’t simply come with successful implementation
• Is a much bigger change than anything most
organizations have previously attempted on
the IT front
Toll-free Call-in number: 1-866-764-6260
27
Critical Success Factors in
Implementation
•
•
•
•
•
Strong leadership and long-term commitment
Creating a culture of innovation
Excellent project management
Attention to clinical processes
A focus on quality
Toll-free Call-in number: 1-866-764-6260
28
Getting Benefits—
What Does It Take?
• Have to have successful implementation
• But also need to decide on a core of decision
support
- Implies having organizational structure enabling
group to reach consensus
• Will have to make many changes
- Need architecture enabling agility
- Sufficient resources to keep up
- Rule is to have a long queue
- Want to start low, go slow—but need to end up with
enough
Toll-free Call-in number: 1-866-764-6260
29
How to Assess Where You Are
Regarding Decision Support
• Use the AHRQ/NQF/Leapfrog assessment
tool
• Gives you a score regarding decision support
• Without doing that hard to assess level of
implementation of decision support
Toll-free Call-in number: 1-866-764-6260
30
The Assessment Methodology
Simulations of EHR Use with CPOE
The assessment pairs medication orders that would cause a serious adverse drug
event with a fictitious patient.
A physician enters the order…
Patient
AB
Female
52 years old
Weighs 60 kg
Allergy to morphine
Normal creatinine
and observes and records the type of CDS-generated advice that is
given (if any).
Coumadin (Warfarin) 5 mg po three times a day.
Toll-free Call-in number: 1-866-764-6260
31
The Assessment Tool
AHRQ/NQF/Leapfrog Assessment Tool
Hospital
logs on
(Password
access)
Obtain
patient
criteria
Complete
sample
test
(Adult or
pediatric)
Program
patient
criteria
(HM if AMB)
Review
patient
descriptions
Hospital selfreports
results
on website
Review
scoring
Score
generated
against
weighted
scheme
Download
and print
30 – 40
test orders
Enter
orders into
CPOE
application
and record
results
Review
orders and
categories
Aggregate
score to
Leapfrog
Report
generated
Order category
scores viewed
by hospital
32
Broader Context
• Multiple technologies can improve
medication safety
- Address different stages of the process
• Bar-coding
• Smart pumps
• Computerized monitoring for ADEs
Toll-free Call-in number: 1-866-764-6260
33
Evidence Regarding Bar-coding
• Increasingly widely used
- About a quarter of hospitals
• Very wide use in VA
• Published evidence base still modest but
growing
• Will be included in meaningful use for 2013
• Likely to be put forward as a safe practice
soon
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34
Dispensing Errors and Potential ADEs:
Before and After Bar-code Technology
Implementation
1.00%
Before Period (115164
doses observed)
After Period (253984
doses observed)
0.88%
0.80%
0.61%
31%
reduction*
0.60%
63%
reduction*
0.40%
0.19%
0.20%
0.07%
0.00%
Dispensing Error Rate
* p<0.0001 (Chi-squared test)
Potential ADE Rate
Projections for errors
prevented per year
at study hospital:
• >13,500 medication
dispensing errors
• >6,000 potential
ADEs
Poon et al., Annals Internal Medicine, 2006
Conclusions
• CPOE appears highly beneficial in the
aggregate
- But can create new problems as well as prevent them
• Need to monitor, engineer out
• Realizing benefits requires:
- Strong implementation
- Later implementation of good decision support
• Important not just to have but to implement
well
- Serial refinements in decision support
• Easiest things are not highest-yield
- Today’s discussion/results very important
Toll-free Call-in number: 1-866-764-6260
36
Using the Re-Engineered
Discharge (RED) to Implement
NQF Safe Practice 15:
Discharge Systems
Kimberly Visconti, RN
Discharge Advocate, Project RED
Boston Medical Center
Toll-free Call-in number: 1-866-764-6260
Safe Practices Webinar
November 19, 2009
37
Background to Current Problem
• Hospital discharge is non-standardized and
frequently marked with poor quality
• Little time spent on discharge teaching
• Patients are not prepared at discharge
• Poor communication between inpatient
and outpatient care
• Communication barriers lead to adverse
events
Toll-free Call-in number: 1-866-764-6260
38
39
Communication Deficits at
Hospital Discharge Are Common
• Discharge summary not readily available:
- Only available for 12%-34% of first post-discharge
appointments
• Discharge summary lacking key components:
- Hospital course (14.5%)
- Discharge medications (21%)
- Completed test results (38%)
- Pending test results (65%)
- Follow-up plans (14%)
- Main diagnosis (17.5%)
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40
Rehospitalizations and Medicare
• 20% of Medicare beneficiaries who had been
discharged from a hospital were readmitted
within 30 days
• The cost of unplanned rehospitalizations in
2004 was $17.4 billion
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41
Major Changes in Hospital Payments
• "Hospitals with high rates of readmission
will be paid less if patients are readmitted to
the hospital within the same 30-day period
saving $26 billion over 10 years"
Obama Administration Budget Document
• MedPAC recommends reducing payments
to hospitals with high readmission rates
MEDPAC Testimony before Congress March ‘09
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42
NQF SP 15 Objective:
“Ensure effective transfer of clinical
information to the patient and ambulatory
clinical providers at the time of discharge."
Toll-free Call-in number: 1-866-764-6260
43
RED meets the NQF SP 15 objective using
11 mutually reinforcing components:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Patient education
Follow-up appointments
Outstanding tests
Post-discharge services
Medication reconciliation
Reconcile DC plan with national guidelines
What to do if problem arises
Assess patient understanding
Written discharge plan for patient
Timely transmission of DC summary to PCP
Post-discharge telephone reinforcement
44
RED Component #1
Educate patient about his/her diagnosis
throughout the hospital stay
• The RED intervention starts within 24 hours of the
patient’s admission to the hospital and continues daily
until discharge
SP 15: “preparation for discharge occurring with
documentation, throughout the hospitalization”
45
RED Component #2
Make appointments for clinician follow-up
and post-discharge testing
• Schedule PCP appt within 2 weeks after discharge
• Review the provider, location, transportation, and plan
to get to appointment
• Consult with patient regarding best day and time for
appointments
• Discuss reason for and importance of all follow-up
appointments and testing
SP 15: “explicit delineation of roles and responsibilities in
the discharge process”
46
RED Component #3
Discuss tests/studies completed and who
will follow up on results
• Information listed in After Hospital Care Plan (AHCP),
which is transmitted to PCP
• Patient knows to discuss this with PCP at follow-up
appointment and where to find it on his/her AHCP
SP 15: “coordination and planning for follow-up appointments that the
patient can keep and follow-up of tests and studies for which confirmed
results are not available at time of discharge”
47
RED Component #4
Organize post-discharge services
• Communicate with case manager and social worker
about post-discharge services that they schedule
• Provide patient with contact information for these
services (phone number, name of company, etc.)
Toll-free Call-in number: 1-866-764-6260
48
RED Component #5
Confirm the Medication Plan
• Reconcile the patient’s home medication list as close to
admission as possible
• Review each medication; make sure that the patient
knows why s/he takes it
• Discuss new medications each day with medical team
and with patient
SP 15: “completion of discharge plan and discharge summaries
before discharge”
49
RED Component #6
Reconcile discharge plan with national
guidelines and critical pathways
• Communicate with medical team each day about the
discharge plan
• Recommend actions that should be taken for each
patient under a given diagnosis
Toll-free Call-in number: 1-866-764-6260
50
RED Component #7
Review appropriate steps for what to do
if a problem arises
• What constitutes an emergency
• What to do if a non-emergent problem arises
• Where to find contact information for the discharge
advocate and PCP on the After Hospital Care Plan
SP 15: “The time from discharge to the first appointment with the
accepting physician represents a period of high risk. All patients
discharged from hospitals should be told what to do if a question or
problem arises, including whom to contact and how to contact them.
Guidance should also be provided about resources for patients’ questions
once they are discharged.”
51
RED Component #8
Expedite transmission of the discharge
summary to the PCP
• Fax the discharge summary and After Hospital Care
Plan to PCP within 24 hours after discharge
SP 15: “reliable information from the primary care physician (PCP) or
caregiver on admission, to the hospital caregivers, and back to the PCP,
after discharge, using standardized communication methods”
“A discharge summary must be provided to the ambulatory clinical
provider who accepts the patient’s care after hospital discharge.”
52
RED Component #9
Assess degree of understanding by asking
patient to explain the details of the plan
• Deliver information to reach those with low health
literacy level
• Include caregivers when appropriate
• Utilize professional interpreters as needed
SP 15: "Before discharge, present a clear explanation that the patient understands
that addresses post-discharge medications, how to take them and how and where
prescription can be filled. This information must also be communicated to the
accepting physician.”
"Use the 'teach-back process' to ensure pt understands transition-of-care planning."
53
RED Component #10
Give the patient a written discharge plan at
time of discharge
• After Hospital Care Plan includes:
1) Principal discharge diagnosis
2) Discharge medication instructions
3) Follow-up appointments with contact
information
4) Pending test results
5) Tests that require follow-up
SP 15: “coordination and planning for follow-up appointments that the
patient can keep and follow-up of tests and studies for which confirmed
results are not available at time of discharge”
54
David Smith
55
56
David Broitman
57
Pharmacist to
call you
58
RED Component #11
Provide telephone reinforcement of the
discharge plan after discharge
•
•
•
•
•
Call patient within 72 hours after discharge
Assess patient status
Review medication plan
Review follow-up appointments
Take appropriate actions to resolve problems
SP 15: “Prospectively identify and provide a mechanism to contact patients
with incomplete or complex discharge plans after discharge to assess the
success of the discharge plan, address questions or issues that have arisen
surrounding it, and reinforce its key components, in order to avoid postdischarge adverse events and unnecessary rehospitalizations"
59
Can Health IT assist with
providing a comprehensive
discharge?
Toll-free Call-in number: 1-866-764-6260
60
New Horizons Using Health IT
Embodied Conversational Agents
• Enhance patient education before discharge
• Emulate face-to-face communication
• Develop therapeutic alliance
• Determines competency
• ECA is currently being
tested at BUMC
Toll-free Call-in number: 1-866-764-6260
Characters: Louise (L) and Elizabeth (R)
Automated Discharge Workflow
SP 15: “the development of IT systems to collect discharge information and create discharge plans
from existing hospital databases could enable components of the plan to be easily collected”
62
Patient interacting with ECA
Thank you!
• For general information about Project
RED, please refer to our website:
http://www.bu.edu/fammed/projectred/
• For information about implementing RED
or obtaining RED software, please contact:
info@engineeredcare.com
Toll-free Call-in number: 1-866-764-6260
64
Practical Implementation Approaches
to Patient Care Information,
Order Read-Back and Abbreviations,
and Labeling of Diagnostic Studies
Peter B. Angood, MD, FRCS(C), FACS, FCCM
Senior Advisor, Patient Safety,
National Quality Forum
Toll-free Call-in number: 1-866-764-6260
Safe Practices Webinar
November 19, 2009
65
Safe Practice 12:
Patient Care Information
Safe Practice 13:
Order Read-Back and Abbreviations
Safe Practice 14:
Labeling of Diagnostic Studies
Toll-free Call-in number: 1-866-764-6260
66
SP 12: Patient Care Information
Ensure that care information is transmitted and
appropriately documented in a timely manner and in
a clearly understandable form to patients and to all of
the patient’s healthcare providers/professionals,
within and between care settings, who need that
information to provide continued care.
Toll-free Call-in number: 1-866-764-6260
67
SP 12:
• The fragmentation of care across many providers, and an
inability to access key care information for patients, results
in very dangerous, yet preventable, scenarios.
• One study reported that only 51% of potentially "life-
threatening" critical test results received appropriate
attention ... audit of patient charts revealed that 15%
contained no documentation that clinicians were ever aware
of the critical test result or that any corrective action was
taken.
• Patient care information, for the purposes of 2009, is defined
as “critical information regarding medical history,
diagnostic test results, medications, treatment, and
procedures.”
68
SP 12:
• This practice instructs organizations how to ensure that
care information is appropriately documented in a timely
manner and clearly communicated to patients and all of the
patient's health care professionals who need that
information to provide continuity of care.
• This practice now includes establishing a process to
communicate critical test results that are completed after
the patient has been discharged from the organization.
Toll-free Call-in number: 1-866-764-6260
69
SP 13: Order Read-Back and
Abbreviations
Incorporate within your organization a safe, effective
communication strategy, structures, and systems to include
the following:
• For verbal or telephone orders or for telephonic reporting of
critical test results, verify the complete order or test result
by having the person who is receiving the information
record and “read-back” the complete order or test result.
• Standardize a list of “Do Not Use” abbreviations, acronyms,
symbols, and dose designations that cannot be used
throughout the organization.
70
SP 13:
• Combined into one 2009 Safe Practice, the activities defined
were merged from 2 separate 2006 Practices … combination
addresses ineffective communication, which is most
frequently cited category of root causes for sentinel events.
• Implementing safeguards to relay accurate patient
information, such as a verbal or telephone order, includes
having the person receiving the information record and
read back the complete order or test result.
Toll-free Call-in number: 1-866-764-6260
71
SP 13:
• Organizations are instructed to standardize a list of "do not
use" abbreviations and dose designations that should not
be used.
• Though now a combined practice, it does not have
substantive changes to the 2006 practice elements.
Toll-free Call-in number: 1-866-764-6260
72
SP 14: Labeling of Diagnostic Studies
Implement standardized policies, processes, and
systems to ensure accurate labeling of radiographs,
laboratory specimens, or other diagnostic studies, so
that the right study is labeled for the right patient at
the right time.
Toll-free Call-in number: 1-866-764-6260
73
SP 14:
• The potential exists for radiographs, laboratory samples,
and pathology specimens to be mislabeled, or incompletely
labeled, and consequently misinterpreted across all care
settings.
• This practice defines implementation of standardized
processes to ensure accurate labeling of diagnostic studies.
• No substantive changes from 2006 practice.
Toll-free Call-in number: 1-866-764-6260
74
Roles for the Patient Advocate
(Are You Listening?)
Arlene Salamendra
Patient Advocate Leader
Former Board Member and Staff Coordinator,
Families Advocating Injury Reduction (FAIR)
Safe Practices Webinar
November 19, 2009
Toll-free Call-in number: 1-866-764-6260
75
76
77
78
Upcoming Safe Practices Webinar
 December 17 – Optimizing a Workforce for Optimal Safe
Care (Safe Practices 9-11)
79