National Healthcare Quality and Disparities Report
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
126 to 150 of 1293 Research Studies DisplayedTokede O, Walji M, Ramoni R
Quantifying dental office-originating adverse events: the dental practice study methods.
Investigators initiated the Dental Practice Study (DPS) with the goal of determining the frequency and types of adverse events (AEs) that occur in dentistry on the basis of retrospective chart audit. In this article, they discussed the 6-month pilot phase of the DPS during which they explored the feasibility and efficiency of their multi-staged review process to detect AEs.
Citation: Tokede O, Walji M, Ramoni R .
Quantifying dental office-originating adverse events: the dental practice study methods.
J Patient Saf 2021 Dec 1;17(8):e1080-e87. doi: 10.1097/pts.0000000000000444..
Keywords: Dental and Oral Health, Adverse Events, Patient Safety, Medical Errors
Ernest EC, Hellar A, Varallo J
Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention.
This study evaluated the impact of a multicomponent safe surgery intervention in Tanzania to reduce surgical site infection (SSI) rates and mortality after caesarean sections (CS). The authors used the WHO Surgical Safety Checklist (SSC) to measure WHO SSC utilization, SSI rates, and CS-related perioperative mortality rates (POMRs) before and 18 months after implementation. The SSC utilization rate for CS increased from 3.7% to 95.1%, which decreased the proportion of women with SSI after CS from 14% during baseline to 1%. CS-related POMR decreased by 38.5% after implementation of safe surgery interventions as well.
AHRQ-funded; HS024235.
Citation: Ernest EC, Hellar A, Varallo J .
Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention.
BMJ Glob Health 2021 Dec;6(12). doi: 10.1136/bmjgh-2021-006788..
Keywords: Maternal Care, Pregnancy, Healthcare-Associated Infections (HAIs), Surgery, Injuries and Wounds, Adverse Events, Patient Safety
Dykes PC, KhasnabishE S, Adkison LE
Use of a perceived efficacy tool to evaluate the FallTIPS program.
The authors assessed nurses' opinions of the efficacy of using the FallTIPS (Tailoring Interventions for Patient Safety) fall prevention program. They found that the nurses who used FallTIPS perceived that efficiencies in patient care compensated for the time spent on FallTIPS. Nurses valued the program, and findings confirmed the importance of patient and family engagement with staff in the fall prevention process.
AHRQ-funded; HS025128.
Citation: Dykes PC, KhasnabishE S, Adkison LE .
Use of a perceived efficacy tool to evaluate the FallTIPS program.
J Am Geriatr Soc 2021 Dec;69(12):3595-601. doi: 10.1111/jgs.17436..
Keywords: Falls, Patient Safety, Prevention, Provider: Nurse, Adverse Events
Giardina TD, Korukonda S, Shahid U
Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.
This retrospective cohort study evaluated the use of patient complaint data to identify patient safety concerns related to diagnosis as an initial step to using this information to facilitate learning and improvement. Patient complaints submitted to the Geisinger healthcare system were reviewed with 2 cohorts from August to December 2017 (cohort 1) and January to June 2018 (cohort 2). The authors selected complaints more likely to be associated with diagnostic concerns in Geisinger’s existing complaint taxonomy. In cohort 1, 1865 complaint summaries were reviewed and 177 (9.5%) were identified as concerning. The review identified 39 diagnostic errors. In cohort 2, 2423 patient complaints were reviewed and 310 (12.8%) concerning reports were identified. A 10% sample contained give diagnostic errors. Most errors were categorized as “Clinical Care” issues.
AHRQ-funded; HS025474; HS027363.
Citation: Giardina TD, Korukonda S, Shahid U .
Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.
BMJ Qual Saf 2021 Dec;30(12):996-1001. doi: 10.1136/bmjqs-2020-011593..
Keywords: Diagnostic Safety and Quality, Patient Safety, Medical Errors, Adverse Events
Orth J, Li Y, Simning A
Nursing home residents with dementia: association between place of death and patient safety culture.
This study examined the association of place of death and patient safety culture among nursing home (NH) residents with dementia. The authors examined the estimated effects of patient safety culture (PSC) among 11,957 long-stay NH residents with dementia, aged 65+ who died in NHs or hospitals shortly following discharge from one of 800 US NHs in 2017. Residents with dementia in NHs with higher PSC scores in communication openness had lower odds of in-hospital death, with the strongest effect in NHs located in states with higher minimum NH nurse staffing requirements.
AHRQ-funded; HS024923.
Citation: Orth J, Li Y, Simning A .
Nursing home residents with dementia: association between place of death and patient safety culture.
Gerontologist 2021 Nov 15;61(8):1296-306. doi: 10.1093/geront/gnaa188..
Keywords: Elderly, Dementia, Nursing Homes, Mortality, Patient Safety
Bender M, Williams M, Cruz MF
A study protocol to evaluate the implementation and effectiveness of the Clinical Nurse Leader care model in improving quality and safety outcomes.
The authors discuss the Clinical Nurse Leader care model, a Hybrid Type II Implementation-Effectiveness study to evaluate the effect of the care model on standardized quality and safety outcomes and to identify implementation characteristics that are sufficient and necessary to achieve outcomes. Findings are expected to elucidate Registered Nurse's mechanisms of action as organized into frontline models of care and link actions to improved care quality and safety.
AHRQ-funded; HS027181.
Citation: Bender M, Williams M, Cruz MF .
A study protocol to evaluate the implementation and effectiveness of the Clinical Nurse Leader care model in improving quality and safety outcomes.
Nurs Open 2021 Nov;8(6):3688-96. doi: 10.1002/nop2.910..
Keywords: Implementation, Quality Improvement, Quality of Care, Patient Safety, Nursing, Evidence-Based Practice
Guo W, Li Y, Temkin-Greener H. W, Li Y, Temkin-Greener H
Community discharge among post-acute nursing home residents: an association with patient safety culture?
Researchers examined whether better patient safety culture (PSC) in skilled nursing facilities was associated with higher likelihood of successful community discharge for post-acute care residents. PSC scores were obtained from a national, random survey conducted in 2017. They found that post-acute care residents who were successfully discharged to community were more likely to be female, white, Medicare-only, cognitively intact, and admitted following a surgery. The multivariable analyses showed that teamwork and supervisor expectations and actions promoting resident safety were significantly associated with the increased likelihood of successful community discharge.
AHRQ-funded; HS024923.
Citation: Guo W, Li Y, Temkin-Greener H. W, Li Y, Temkin-Greener H .
Community discharge among post-acute nursing home residents: an association with patient safety culture?
J Am Med Dir Assoc 2021 Nov;22(11):2384-88.e1. doi: 10.1016/j.jamda.2021.04.022..
Keywords: Elderly, Nursing Homes, Patient Safety
Vaughan CP, Hwang U, Vandenberg AE
Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme.
Enhancing quality of prescribing practices for older adults discharged from the Emergency Department (EQUIPPED) aims to reduce the monthly proportion of potentially inappropriate medications (PIMs) prescribed to older adults discharged from the ED to 5% or less. In this paper, the investigator described prescribing outcomes at three academic health systems adapting and sequentially implementing the EQUIPPED medication safety programme.
AHRQ-funded; HS024499.
Citation: Vaughan CP, Hwang U, Vandenberg AE .
Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme.
BMJ Open Qual 2021 Nov;10(4). doi: 10.1136/bmjoq-2021-001369..
Keywords: Elderly, Medication: Safety, Medication, Patient Safety, Emergency Department, Quality Improvement, Quality of Care
Oberlander T, Scholle SH, Marsteller J
Implementation of patient safety structures and processes in the patient-centered medical home.
This study's objectives were to identify patient-centered medical home (PCMH) standards relevant to patient safety, to construct a measure of patient safety activity implementation, and to examine differences in adoptions of these activities by practice and community characteristics. Findings showed that implementation of patient safety activities varied; the few military practices studied had the highest, and community clinics the lowest, patient safety score, both overall and across specific domains, while other practice and community characteristics were not associated with the patient safety score.
AHRQ-funded; HS024859.
Citation: Oberlander T, Scholle SH, Marsteller J .
Implementation of patient safety structures and processes in the patient-centered medical home.
J Healthc Qual 2021 Nov-Dec;43(6):324-39. doi: 10.1097/jhq.0000000000000312..
Keywords: Patient-Centered Healthcare, Patient Safety, Implementation, Primary Care
Lasser EC, Heughan JA, Lai AY
Patient perceptions of safety in primary care: a qualitative study to inform care.
The authors sought to understand the patient perspective on patient safety in patient-centered medical homes (PCMHs). Using focus groups/interviews, they found overarching themes focused on (1) clear and timely communication with and between clinicians and (2) trust in the care team, including being heard, respected, and treated as a whole person. Other themes included sharing of and access to information, patient education and patient-centered medication reconciliation process, clear documentation for the diagnostic process, patient-centered comprehensive visits, and timeliness of care.
AHRQ-funded; HS024859.
Citation: Lasser EC, Heughan JA, Lai AY .
Patient perceptions of safety in primary care: a qualitative study to inform care.
Curr Med Res Opin 2021 Nov;37(11):1991-99. doi: 10.1080/03007995.2021.1976736..
Keywords: Patient Safety, Patient Experience, Primary Care, Patient-Centered Healthcare
Nehls N, Yap TS, Salant T
Systems engineering analysis of diagnostic referral closed-loop processes.
This systems engineering (SE) analysis of diagnostic referral closed-loop processes examines process logic, variation, reliability, and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case. Research has shown that there is a 65-73% failure rate in completing diagnostic referrals, which is a significant patient safety problem. An interdisciplinary team collaborated to understand processes of initiating and completing diagnostic referrals. Cross-functional process maps were developed through iterative group interviews with an urban community-based health center and a teaching practice within a large academic medical center. Results were used to conduct an engineering process analysis, assess variation between and within practices, and identify common failure modes and potential solutions.
AHRQ-funded; HS027282.
Citation: Nehls N, Yap TS, Salant T .
Systems engineering analysis of diagnostic referral closed-loop processes.
BMJ Open Qual 2021 Nov;10(4). doi: 10.1136/bmjoq-2021-001603..
Keywords: Diagnostic Safety and Quality, Primary Care, Patient Safety
Bayramzadeh S, Anthony MK, Sterling M
The role of the physical environment in shaping interruptions and disruptions in complex health care settings: a scoping review.
This scoping review investigated the impact of the physical environment on interruptions and disruptions and the associated outcomes in complex environments, as they relate to the components of the Systems Engineering Initiative for Patient Safety. Findings showed that poor layout configurations, tripping hazards, and technology integration were common examples of compromised workflow and safety issues due to the physical environment's characteristics.
AHRQ-funded; HS027261.
Citation: Bayramzadeh S, Anthony MK, Sterling M .
The role of the physical environment in shaping interruptions and disruptions in complex health care settings: a scoping review.
Am J Med Qual 2021 Nov-Dec;36(6):449-58. doi: 10.1097/jmq.0000000000000005..
Keywords: Healthcare Delivery, Patient Safety
Reese TJ, Del Fiol G, Morgan K
A shared decision-making tool for drug interactions between warfarin and nonsteroidal anti-inflammatory drugs: design and usability study.
Exposure to life-threatening drug-drug interactions (DDIs) occurs despite the widespread use of clinical decision support. The DDI between warfarin and nonsteroidal anti-inflammatory drugs is common and potentially life-threatening. Patients can play a substantial role in preventing harm from DDIs; however, the current model for DDI decision-making is clinician centric. This study aimed to design and examine the usability of DDInteract, a tool to support shared decision-making (SDM) between a patient and provider for the DDI between warfarin and nonsteroidal anti-inflammatory drugs.
AHRQ-funded; HS026198.
Citation: Reese TJ, Del Fiol G, Morgan K .
A shared decision-making tool for drug interactions between warfarin and nonsteroidal anti-inflammatory drugs: design and usability study.
JMIR Hum Factors 2021 Oct 26;8(4):e28618. doi: 10.2196/28618..
Keywords: Blood Thinners, Medication: Safety, Medication, Clinical Decision Support (CDS), Decision Making, Electronic Health Records (EHRs), Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Patient Safety
Arntson E, Dimick JB, Nuliyalu U
Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.
This study evaluated changes in Hospital-Acquired Conditions (HACs) and 30-day mortality after the announcement of the Centers for Medicare and Medicare Services’ Hospital-Acquired Condition Reduction Program (HACRP) in August 2013. The authors evaluated models to test for changes in HACs and 30-day mortality before and after the Affordable Care Act (ACA), and after the HACRP. Fee-for-service Medicare claims from 2009 to 2015 were used. The HAC rate declined after the ACA was passed and declined further after the HACRP announcement. However, 30-day mortality rates were unchanged.
AHRQ-funded; HS026244.
Citation: Arntson E, Dimick JB, Nuliyalu U .
Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.
Ann Surg 2021 Oct 1;274(4):e301-e07. doi: 10.1097/sla.0000000000003641..
Keywords: Healthcare-Associated Infections (HAIs), Hospitals, Mortality, Medicare, Payment, Prevention, Patient Safety
Murphy DR, Savoy A, Satterly T
Dashboards for visual display of patient safety data: a systematic review.
Methods to visualize patient safety data can support effective monitoring of safety events and discovery of trends. While quality dashboards are common, use and impact of dashboards to visualize patient safety event data remains poorly understood. The objective of this study was to understand development, use and direct or indirect impacts of patient safety dashboards. The investigators conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
AHRQ-funded; HS022087; HS022901; HS027363.
Citation: Murphy DR, Savoy A, Satterly T .
Dashboards for visual display of patient safety data: a systematic review.
BMJ Health Care Inform 2021 Oct;28(1). doi: 10.1136/bmjhci-2021-100437..
Keywords: Patient Safety, Health Services Research (HSR)
Fauer A, Wright N, Lafferty M
Influences of physical layout and space on patient safety and communication in ambulatory oncology practices: a multisite, mixed method investigation.
Researchers examined how physical layouts and space in ambulatory oncology practices influence patient safety and clinician communication. They found that the physical layout affected communication around chemotherapy infusion and ultimately patient safety. Two themes emerged: visibility of patients during infusion and proximity of clinicians in the infusion center to clinicians in the clinic where providers see patients. They concluded that their findings informed efforts to construct new and to modify existing infusion centers to enhance patient safety and clinician communication.
AHRQ-funded; HS024914.
Citation: Fauer A, Wright N, Lafferty M .
Influences of physical layout and space on patient safety and communication in ambulatory oncology practices: a multisite, mixed method investigation.
HERD 2021 Oct;14(4):270-86. doi: 10.1177/19375867211027498..
Keywords: Patient Safety, Communication
Herzig SJ, Anderson TS, Jung Y
Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: a nationwide cohort study.
This retrospective cohort study’s objective was to determine the incidence and risk of post-discharge adverse events among opioid claims in the week after hospital discharge, compared to those with nonsteroidal anti-inflammatory drugs (NSAIDs) claims alone. A national sample of Medicare beneficiaries age 65 and older who were hospitalized in the United States in 2016 was used. Beneficiaries who were admitted from or discharged to a facility were excluded. The authors used 3:1 propensity matching to match beneficiaries with an opioid claim in the week after discharge (13,385) with beneficiaries with NSAID claim alone (4,677). Beneficiaries receiving opioids had a higher incidence of death, healthcare utilization, and any potential adverse effect compared to those with an NSAID claim only. Specific adverse effects included higher relative risk of fall/fracture, nausea/vomiting, and slowed colonic motility.
AHRQ-funded; HS026215.
Citation: Herzig SJ, Anderson TS, Jung Y .
Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: a nationwide cohort study.
PLoS Med 2021 Sep 27;18(9):e1003804. doi: 10.1371/journal.pmed.1003804..
Keywords: Elderly, Opioids, Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Risk, Hospital Discharge
Fong A, Adams K, Samarth A
AHRQ Author: Chappel T, Grace E, Terrillion S
Assessment of automating safety surveillance from electronic health records: Analysis for the quality and safety review system.
Researchers provided a heuristic assessment of the feasibility of automatically populating the Quality and Safety Review System (QSRS) questions from electronic health record (EHR) data. They developed the Relative Abstraction Complexity Framework to assess relative complexity of data abstraction questions. Their results suggested that Blood and Hospital Acquired Infections-Clostridium Difficile Infection (HAI-CDI) modules would be relatively easier to automate, whereas Surgery and HAI-Surgical Site Infection would be more difficult to automate.
AHRQ-authored; AHRQ-funded; 290201400008I.
Citation: Fong A, Adams K, Samarth A .
Assessment of automating safety surveillance from electronic health records: Analysis for the quality and safety review system.
J Patient Saf 2021 Sep 1;17(6):e524-e28. doi: 10.1097/pts.0000000000000402..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Pakyz AL, Wang H, Ozcan YA
Leapfrog Hospital Safety Score, magnet designation, and healthcare-associated infections in United States hospitals.
The goal of this study was to determine whether Magnet designation and hospitals with better Leapfrog Hospital Safety Scores have fewer healthcare-associated infections (HAIs). Findings showed that “A” hospitals performed better on clostridium difficile infection (CDI) but not methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections, while Magnet designation was associated with fewer than expected MRSA infections but more than expected CDIs. These mixed results show that hospital global assessments of safety and workplace quality differentially and imperfectly predict its level of HAIs.
AHRQ-funded; HS018578.
Citation: Pakyz AL, Wang H, Ozcan YA .
Leapfrog Hospital Safety Score, magnet designation, and healthcare-associated infections in United States hospitals.
J Patient Saf 2021 Sep 1;17(6):445-50. doi: 10.1097/pts.0000000000000378..
Keywords: Methicillin-Resistant Staphylococcus aureus (MRSA), Healthcare-Associated Infections (HAIs), Hospitals, Patient Safety
Puthumana JS, Fong A, Blumenthal J
Making patient safety event data actionable: understanding patient safety analyst needs.
The increase in patient safety reporting systems has led to the challenge of effectively analyzing these data to identify and mitigate safety hazards. Patient safety analysts, who manage reports, may be ill-equipped to make sense of report data. The investigators sought to understand the cognitive needs of patient safety analysts as they worked to leverage patient safety reports to mitigate risk and improve patient care.
AHRQ-funded; HS023874.
Citation: Puthumana JS, Fong A, Blumenthal J .
Making patient safety event data actionable: understanding patient safety analyst needs.
J Patient Saf 2021 Sep 1;17(6):e509-e14. doi: 10.1097/pts.0000000000000400..
Keywords: Patient Safety, Hospitals
Mahajan P, Pai CW, Cosby KS
Identifying trigger concepts to screen emergency department visits for diagnostic errors.
The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. In this study, the investigators sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm.
AHRQ-funded; HS024953; HS027363.
Citation: Mahajan P, Pai CW, Cosby KS .
Identifying trigger concepts to screen emergency department visits for diagnostic errors.
Diagnosis 2021 Aug 26;8(3):340-46. doi: 10.1515/dx-2020-0122..
Keywords: Emergency Department, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety
Piatkowski M, Taylor E, Wong B
Designing a patient room as a fall protection strategy: the perspectives of healthcare design experts.
This multi-year study aimed to better understand how patient room design can increase stability during ambulation, serving as a fall protection strategy for frail and/or elderly patients. Specifically, the aim of this portion of the study was to ascertain the architect's perspective on designing a room to mitigate the risk of falls, as well as to evaluate the face validity of a predictive algorithm to assess risk in room design using the input of a design advisory council (AC).
AHRQ-funded; HS025606.
Citation: Piatkowski M, Taylor E, Wong B .
Designing a patient room as a fall protection strategy: the perspectives of healthcare design experts.
Int J Environ Res Public Health 2021 Aug 19;18(16). doi: 10.3390/ijerph18168769..
Keywords: Falls, Patient Safety, Prevention, Adverse Events, Inpatient Care
Krein SL, Harrod M, Weston LE
Comparing peripherally inserted central catheter-related practices across hospitals with different insertion models: a multisite qualitative study.
Researchers compared peripherally inserted central catheters (PICCs)-related processes across hospitals with different insertion delivery models. They concluded that vascular access nurses play critical roles in all aspects of PICC-related care. Further, there is variation in PICC decision-making, care and maintenance, and patient education across hospitals.
AHRQ-funded; HS025891.
Citation: Krein SL, Harrod M, Weston LE .
Comparing peripherally inserted central catheter-related practices across hospitals with different insertion models: a multisite qualitative study.
BMJ Qual Saf 2021 Aug;30(8):628-38. doi: 10.1136/bmjqs-2020-011987..
Keywords: Inpatient Care, Decision Making, Patient Safety, Hospitals
Cifra CL, Custer JW, Singh H
Diagnostic errors in pediatric critical care: a systematic review.
This study is a systematic review on the prevalence, impact, and contributing factors related to diagnostic errors in the PICU. A database search was done for literature up through December 2019. Using specific criteria, 396 abstracts were screened, and 17 studies were included. Fifteen of 17 studies had an observational research design. Autopsy studies showed a 10-23% rate of missed major diagnosis with 5-16% of the errors having a potential adverse impact on survival and would have changed care management. Retrospective record review studies reported varying rates of diagnostic error from 8% in a general PICU population to 12% among unexpected critical admissions. About a quarter of those patients were discussed at PICU morbidity and mortality conferences. Most misdiagnosed conditions were cardiovascular, infectious, congenital, or neurologic. System, cognitive, and both system and cognitive factors were associated with diagnostic error but there is limited information on the impact of misdiagnosis.
AHRQ-funded; HS026965.
Citation: Cifra CL, Custer JW, Singh H .
Diagnostic errors in pediatric critical care: a systematic review.
Pediatr Crit Care Med 2021 Aug;22(8):701-12. doi: 10.1097/pcc.0000000000002735..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Intensive Care Unit (ICU), Critical Care
De Oliveira GS, Castro-Alves LJ, Kendall MC
Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.
The main objective of the current investigation was to examine the effectiveness of pharmacist-based transition-of-care interventions on the reduction of medication errors after hospital discharge. Findings showed that pharmacist transition-of-care intervention is an effective strategy to reduce medication errors after hospital discharge and also reduces subsequent emergency room visits.
AHRQ-funded; HS024158.
Citation: De Oliveira GS, Castro-Alves LJ, Kendall MC .
Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.
J Patient Saf 2021 Aug 1;17(5):375-80. doi: 10.1097/pts.0000000000000283..
Keywords: Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety, Provider: Pharmacist, Transitions of Care