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Complication Rates for Fluoroscopic Guided Interlaminar Lumbar Epidural Steroid Injections Performed by Certified Registered Nurse Anesthetists in Diverse Practice Settings

Journal for Healthcare Quality -

Abstract Study question

What is the complication rate for Certified Registered Nurse Anesthetists (CRNAs) performing fluoroscopic guided lumbar epidural steroid injections (LESIs)?

Methods

CRNA pain practitioners responded to questionnaires regarding their education level, experience, and practice locations. Participants also collected data on number of fluoroscopic guided LESIs performed and each of 20 complications for a 6‐month period, and answered a poll regarding satisfaction with the data collection process.

Results

Participants represented urban (23%) and rural (77%) practices; as well as office/clinic (31%) hospital (62%) and mixed (7%) practice settings. Both Masters (62%) and Doctoral prepared (38%) CRNAs participated. Their experience in performing fluoroscopic guided LESIs ranged from 1 to 17 years and 50 to 12,000 procedures. Rate of occurrence for each complication was below 1%. Participants had higher rates of bruising and vasovagal reactions than other complications. No paralysis or death occurred. Neither practice setting nor experience level was related to complication rates. Participants expressed interest in participating in additional studies of complication rates.

Conclusion

CRNAs were able to safely and effectively perform fluoroscopic guided LESIs with complication rates similar to physician rates cited in the literature. Additional study of definitions of complications and CRNA complication rates for other pain management procedures is recommended.

The Patient‐Centered Discharge—An Electronic Discharge Process Is Associated With Improvements in Quality and Patient Satisfaction

Journal for Healthcare Quality -

Abstract

In this retrospective cohort study, 100 records were randomly selected from the intervention period (April 2012) and the control period (April 2011). The hospital's institutional database was queried to compare mortality, length of stay, and patient satisfaction, in the year prior to and the year after the integration of the new process. A chart review was performed to determine if the reengineered process was associated with an improvement in documentation. A scoring system was developed to gauge the quality and timeliness of the process. Institutional data regarding length of stay, mortality, patient satisfaction, and core measures compliance were compared for the pre– and postimplementation of the new process. The reengineered discharge process was associated with an improvement in patient satisfaction and in the quality of the discharge materials as measured by the “patient–centered transitions of care (PCTC) score.” These improvements occurred without a significant increase in the time to complete a discharge.

A redesigned discharge process resulted in system–wide improvements in the quality of information provided to the patient and their outpatient providers. This intervention was associated with an improvement in compliance with core measures, improvements in patient satisfaction and timeliness of discharge summary preparation.

Interview with a Quality Leader: Dr. John Combes on Boards and Governance

Journal for Healthcare Quality -

Abstract

Dr. Combes is senior vice president at the American Hospital Association (AHA) and president and COO of the Center for Healthcare Governance. The Interview with Dr. John Combes on Boards and Governance provides a perspective on key changes, issues, competencies, and metrics that hospital boards must address. The role of quality professionals to be effective with boards is also described.

Wireless Communication in Clinical Environments with Unique Needs

Journal for Healthcare Quality -

Abstract

Wireless technology in healthcare has been associated with communication‐related improvements in workflow; however, there are barriers to adoption. This study examined predictors of use of wireless communication devices (WCDs) in environments with unique needs (i.e., intensive care unit [ICU]). Nurses were recruited in the ICU to complete a paper questionnaire to assess their willingness to use WCDs. The Theory of Planned Behaviour was used to assess attitudes, subjective norms, perceived control, and behavioral intent. Responses included Likert scale scores and open‐ended questions. Data were collected before and following the implementation of WCDs in ICU. The combined effects of attitudes, perceived control and subjective norms on behavioral intent were tested using the general linear model. The narrative data were analyzed using a thematic analysis approach. Attitudes and subjective norms were predictors of behavioral intent to use WCDs preimplementation but not postimplementation. Differences in the factors affecting intent to use WCDs between the ICU and the surgical unit may be related to the unique nature of the critical care environment, and to the lack of a comprehensive preimplementation strategy. A study examining predictors of use on a general inpatient unit where a comprehensive implementation strategy was not employed would provide insight into whether these findings are related to the implementation strategy or the unique nature of the critical care environment. Improved understanding of the function and application of innovative technology at the point of care, and attention to the process of implementation may improve adoption of this potentially beneficial device.

Improving Completion Rates for Client Intake Forms through Audio Computer‐Assisted Self‐Interview (ACASI): Results from a Pilot Study with the Avon Breast Health Outreach Program

Journal for Healthcare Quality -

Abstract

This study compares rates of completion of client intake forms (CIFs) collected via three interview modes: audio computer‐assisted self‐interview (ACASI), face‐to‐face interview (FFI), and self‐administered paper‐based interview (SAPI). A total of 303 clients served through the Avon Breast Health Outreach Program (BHOP) were sampled from three U.S. sites. Clients were randomly assigned to complete a standard CIF via one of the three interview modes. Logistic regression analyses demonstrated that clients were significantly more likely to complete the entire CIF via ACASI than either FFI or SAPI. The greatest observed differences were between ACASI and SAPI; clients were almost six times more likely to complete the CIF via ACASI as opposed to SAPI (AOR = 5.8, p < .001). We recommend that where feasible, ACASI be utilized as an effective means of collecting client‐level data in healthcare settings. Adoption of ACASI in health centers may translate into higher completion rates of intake forms by clients, as well as reduced burden on clinic staff to enter data and review intake forms for completion.

Eliminating Visiting Hour Restrictions in Hospitals

Journal for Healthcare Quality -

Abstract Background

Hospitals typically restrict visiting hours to ensure a restful environment for patients and to allow clinical staff to work. With increased public reporting focused on patient satisfaction and renewed efforts to improve patient and family engagement, hospitals may want to consider evaluating their current restrictions on visitation. Liberal visitation practices can decrease patient anxiety and benefit patients and families.

Methods

Morristown Medical Center, a 690‐bed tertiary acute care facility and a 78‐bed rehabilitation hospital, initiated a 24‐h visitation policy. With input from nurses, physicians, administrators, and security, we developed a policy that emphasizes patient and staff safety and places the patient at the center of decision making. Comparison of patient satisfaction scores before and after the open visitation policy was implemented, which was made using the chi‐square test.

Results

In the first 8 months of the open visitation policy, the medical center received 14,444 “after‐hours” (8:00 p.m. to 5:00 a.m.) visitors. During this period, there was no increase in the number of complaints from patients or visitors. Incidence of security events did not change, despite the higher number of visitors. Patient satisfaction scores rose on both a commercial satisfaction survey and on the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Unit staff received fewer phone calls for patient updates and acknowledged that the experience had been positive.

Discussion

Our experience suggests that implementation of open visitation at acute care and long‐term care institutions can be accomplished with little disruption, is well utilized by visitors, improves the patient and family experience, and is generally accepted by hospital staff.

Success of the 4 Pillars Toolkit for Influenza and Pneumococcal Vaccination in Adults

Journal for Healthcare Quality -

Abstract Background

Standing order programs (SOPs) allowing nonphysician personnel to assess patients’ immunization status and administer vaccines without an individual physician order are a proven method of increasing adult vaccinations, yet they are underutilized by primary care physicians.

Methods

In a before‐and‐after trial, a pilot‐tested and revised SOP toolkit (4 Pillars Toolkit) was implemented in four diverse primary care practices. Changes in influenza and pneumococcal polysaccharide vaccine (PPSV) vaccination rates were measured. The toolkit was evaluated using direct observation, group interviews, and surveys of each practice's staff.

Results

Use of the 4 Pillars Toolkit varied across sites. PPSV rates increased significantly overall for high‐risk adults (18–64 years; 25% in 2010–2011 vs. 40% in 2011–2012, p = .02) but not for older adults (≥65 years; 44% vs. 52%, p = .26) and in two of four practices among both high‐risk and older adults (p < .05). Influenza vaccination rates increased significantly in three of four sites and overall (22% in 2010–2011 vs. 33% in 2011–2012, overall; p < .001). Practices more fully implementing the toolkit demonstrated larger increases in vaccination rates.

Conclusions

The 4 Pillars Toolkit is a promising means of improving primary care practice across diverse settings, with better results observed when strategies were maximally utilized.

Implementation and Evaluation of a Low Health Literacy and Culturally Sensitive Diabetes Education Program

Journal for Healthcare Quality -

Abstract

Low health literacy is more prevalent in persons with limited education, members of ethnic minorities, and those who speak English as a second language, and is associated with multiple adverse diabetes‐related health outcomes. This study examined the effectiveness of a low health literacy and culturally sensitive diabetes education program for economically and socially disadvantaged adult patients with type 2 diabetes. A pre–post prospective study design was used to examine outcomes over 12 months. Outcome measures included diabetes knowledge, self‐efficacy, and self‐care, measured using reliable and valid survey tools, and A1C. Over this period of time 277 patients were enrolled in the program, with 106 participants completing survey data. At the completion of the program patients had significant improvements in diabetes knowledge (p < .001), self‐efficacy (p < .001), and three domains of self‐care including diet (p < .001), foot care (p < .001), and exercise (p < .001). There were no significant improvements in the frequency of blood glucose testing (p = .345). Additionally, A1C values significantly improved 3 months after completing the program (p = .007). In conclusion, a diabetes education program designed to be culturally sensitive and meet the needs of individuals with low health literacy improves short‐term outcomes.

Improving Medication Administration Safety: Using Naïve Observation to Assess Practice and Guide Improvements in Process and Outcomes

Journal for Healthcare Quality -

Abstract Purpose

To present findings from the Collaborative Alliance for Nursing Outcomes’ (CALNOC) hospital medication administration (MA) accuracy assessment in a sample of acute care hospitals. Aims were as follows: (1) to describe the CALNOC MA accuracy assessment, (2) to examine nurse adherence to six safe practices during MA, (3) to examine the prevalence of MA errors in adult acute care, and (4) to explore associations between safe practices and MA accuracy.

Methods

Using a cross‐sectional design, point in time, and convenience sample, direct observation data were collected by 43 hospitals participating in CALNOC's benchmarking registry. Data included 33,425 doses from 333 observation studies on 157 adult acute care units. Results reveal that the most common MA safe practice deviations were distraction/interruption (22.89%), not explaining medication to patients (13.90%), and not checking two forms of ID (12.47%). The most common MA errors were drug not available (0.76%) and wrong dose (0.45%). The overall percentage of safe practice deviations per encounter was 11.40%, whereas the overall percentage of MA errors was 0.32%.

Conclusions and Implications

Findings predict that for 10,000 MA encounters, 27,630 safe practice deviations and 770 MA errors will occur. A 36% reduction in practice deviation per encounter prevents 4.4% MA errors. Ultimately, reliably performing safe practices improves MA accuracy.

Hospital‐Acquired Conditions After Orthopedic Surgery Do Not Affect Patient Satisfaction Scores

Journal for Healthcare Quality -

Abstract Introduction

The purpose of this study was to determine whether development of a hospital‐acquired condition (HAC) affected responses to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions. HCAHPS is a national, standardized satisfaction survey. Patient responses form, in part, the basis for Medicare reimbursement to hospitals via the value‐based purchasing system established by the Patient Protection and Affordable Care Act of 2010. We hypothesized that patients who developed an HAC would be less satisfied with their care.

Methods

We randomly distributed the HCAHPS survey, a validated, standardized measure of patient satisfaction, to 6,056 patients discharged from our institution for any orthopedic admission over a 2‐year period. All patients who develop HACs are logged by our hospital quality assurance monitoring system. We reviewed the HCAHPS database, identified completed surveys associated with patients who had developed an HAC, and compared satisfaction scores between patients with HACs and patients without HACs. Survey scores were normalized to a 100‐point scale. Univariate analysis was performed for two global ratings, and six specific satisfaction categories. Subgroup analysis was performed for surgical site infections (SSIs) and venous thromboembolic disease (VTE).

Results

A total of 2,876 controls and 159 HAC cases were identified from completed surveys. The cases and controls were similar in terms of race, however, the HAC group contained significantly more women (p < .001). Patients in the HAC group also were, on average, significantly older, with a mean age of 66.84 versus 58.65 (p < .001). There was no difference in satisfaction scores in patients’ mean rating of communication by nurses (p = .81), communication by doctors (p = .31), communication about medications (p = .69), pain control (p = .66), the cleanliness of the hospital environment (p = .54), and the quietness of the hospital (p = .589). The mean normalized score for overall satisfaction was 93.99 (out of 100) for controls and 94.84 for HAC cases (p = .61). The mean normalized score for overall willingness to recommend the hospital to others was 90.22 for controls and 90.65 for HAC cases (p = .77). There was no statistically significant difference in satisfaction for patients with SSI versus VTE versus all other HACs (p > .05).

Discussion

Performance on HCAHPS is an area that demands hospital attention both to provide patient‐centered care and to maximize revenue. Development of an HAC was not associated with decreased satisfaction scores in a population of orthopedic surgery patients at a private, university‐affiliated specialty center. The lack of any statistically significant difference in patient satisfaction may be attributable to patient satisfaction with care in response to complications, the decreased sensitivity inherent to using a general satisfaction survey, or a homogeneity among orthopedic surgery patients and their expectations of care.

VHA Patient‐Centered Medical Home Associated With Lower Rate of Hospitalizations and Specialty Care Among Veterans With Posttraumatic Stress Disorder

Journal for Healthcare Quality -

Abstract Objective

The Veterans Health Administration (VHA) implemented a patient‐centered medical home (PCMH) model, termed Patient Aligned Care Teams (PACT), in 2010. We assessed the association between PACT and the use of health services among U.S. veterans with posttraumatic stress disorder (PTSD).

Methods

VHA clinical and administrative data were obtained for the pre‐PACT period of April 1, 2009 to March 31, 2010 and post‐PACT period of June 1, 2011 to May 31, 2012. Outcomes included hospitalizations, primary, specialty and mental health visits, and emergency department and urgent care visits. We utilized negative binomial regression and extended estimating equation models for the full sample. The analysis contained 696,379 unique veterans in both pre‐ and post‐PACT periods. We estimated the linear incremental effect of PACT on utilization outcomes.

Results

PACT were associated with a decrease in hospitalizations (incremental effect [IE]: −0.02; 95% confidence interval [CI]: −0.03, −0.01), a decrease in specialty care visits (IE: −0.45; 95% CI: −0.07, −0.23), and an increase in primary care visits (IE: 0.96; 95% CI: 0.67, 1.25).

Conclusions

The period following PACT implementation was associated with a lower rate of hospitalizations and specialty care visits, and a higher rate of primary care visits for veterans with PTSD, indicating enhanced access to primary care.

Asthma Care Quality Measures at Children's Hospitals and Asthma‐Related Outcomes

Journal for Healthcare Quality -

Abstract Objective

The Joint Commission requires hospitals to report on Children's Asthma Care (CAC) measures, although their relationship to outcomes is not clear. The objective of this study was to (1) characterize metrics hospitals use for asthma, and to (2) determine if the number and type of metrics used is associated with readmission rates.

Study Design

Pediatric hospital quality leaders were asked to identify asthma metrics utilized by their respective organizations via an online survey. “Use” of metrics was defined as periodically measuring data regardless of performance. Linear regression was used to determine if the number or domain of metrics grouped by topic used was associated with 7‐, 30‐, and 90‐day same‐cause readmission rates obtained from the Pediatric Health Information System (PHIS).

Results

Among respondents (n = 27, 62.7%), the mean number of metrics used was 20.5 (SD = 9.1, range = 4–38). There was no association between the number or domain type of metrics used and 7‐, 30‐, or 90‐day readmission rates.

Conclusions

Despite using a wide variety of asthma metrics, there was no association between use of any metric or domain of metrics and asthma‐related readmission rates. Additional work should identify asthma process measures that are associated with meaningful outcomes.

Brief Report on Obstetricians’/Gynecologists’ Distribution of Scarce Resources

Journal for Healthcare Quality -

Abstract

On a day‐to‐day basis, doctors must decide which treatments are most beneficial for their patients, and which make the most sense in terms of costs. In medical decision making, factors such as efficiency and cost‐effectiveness can be particularly challenging to navigate because many of the most expensive procedures encountered in medical practice are also high‐stake treatments for patients. One‐hundred‐six obstetricians–gynecologists (Obs/Gyns) completed a survey asking them to allocate the following resources in scenarios in which they are scarce: human papilloma virus (HPV) vaccinations, mammograms, and in vitro fertilization (IVF) treatments. Additional questions focused on how fairness and cost‐effectiveness factored into the allocation decisions of each group. Results indicated that Obs/Gyns were more efficient in their distribution of HPV vaccinations and mammograms than in their distribution of IVF treatments. More efficient responding was associated with placing less emphasis on fairness in decision making. This study demonstrates the differences that exist in the emphasis that physicians place on medical evidence, cost, outcomes, and perceptions of fair (equal) allocation when faced with different costs and health impacts.

Patient Needs, Required Level of Care, and Reasons Delaying Hospital Discharge for Nonacute Patients Occupying Acute Hospital Beds

Journal for Healthcare Quality -

Abstract

This study aims to determine the proportion of nonacute patients occupying acute care beds and to describe their needs, the appropriate level of alternative care, and reasons preventing discharge. Data from 952 patients hospitalized in an acute care unit for 30 days were obtained from their medical charts and by consulting with the medical team at two tertiary teaching hospitals. Among them, 333 (35%) were determined nonacute on day 30 of hospitalization. According to the Appropriateness Evaluation Protocol (AEP), 55% had no medical, nursing, or patient needs. Among nonacute patients with AEP needs, 88% were related to nursing/life‐support services and 12% related to patient condition factors. Regarding alternative level of care, 186 (56%) were waiting for out‐of‐hospital resources, of which 36% were waiting for palliative care, 33% for long‐term care, 18% for rehabilitation, and 12% for home care. For the remaining 147 (44%) nonacute patients, the alternative resources remained undetermined although acute care was no longer required. Main reasons preventing discharge included unavailability of alternative resources, ongoing assessment to determine appropriate resources, ongoing process with community care, and family/patient education/counseling. Available subacute facilities and community‐based care would liberate acute care beds and facilitate their appropriate use.

Improvement through Small Cycles of Change: Lessons from an Academic Medical Center Emergency Department

Journal for Healthcare Quality -

Abstract

This article describes the experiences of a quality improvement team that used small cycles of change to improve the emergency department (ED) of an academic medical center. The role of EDs in the provision of healthcare continues to increase in importance. ED bottlenecks contribute to long waits and diminished outcomes for ED patients as well as more system‐wide issues, such as inefficiencies in inpatient admission processes. The purpose of this “ED Operational Efficiency Project” was to reduce lengths of stay (LOS) for low‐acuity patients. The team used lean management techniques to both improve services and shift the ED culture to prioritize continuous quality improvement. The goal to reduce LOS by 30% was met as the result of several interrelated projects (or small cycles of change). Key lessons include monitoring metrics, communicating with teams and target populations, learning from initial failures, using small wins to increase momentum, and anchoring changes.

Did We Have an Impact? Changes in Racial and Ethnic Composition of Patient Populations Following Implementation of a Pilot Program

Journal for Healthcare Quality -

Abstract

High‐quality data are necessary to eliminate health disparities, and are necessary in cancer prevention and control. A pilot project to improve the collection of race and ethnicity data was undertaken. The approach included train‐the‐trainer and staff training, and racial and ethnic categories were expanded to include “granular ethnicity” or ancestry terms in the patient registration system at five acute care hospitals in Rhode Island. The self‐reported racial and ethnic distribution of the patient population was examined for each pilot hospital. Two of the five pilot hospitals reported significant increases in the identification of Hispanic patients. At two other pilot hospitals, the proportion reporting unknown on either race or ethnicity was reduced. Evidence that Hispanics struggle to identify with existing racial categories is also highlighted. These results suggest that a modest program of staff training and resources can significantly increase the identification of racial and ethnic minorities, improving the quality of hospital and state cancer registry data. This has many possible benefits, including better alignment with language services for the patient population, better understanding of the healthcare needs of different racial and ethnic groups, and better strategies to not only address disparities, but also assess those efforts.

Family Physicians’ Quality Interventions and Performance Improvement for Hypertension through Maintenance of Certification

Journal for Healthcare Quality -

Abstract Purpose

Hypertension is a cause of considerable morbidity and mortality. Our objective was to describe the quality outcomes associated with physicians’ completion of hypertension Performance in Practice Modules (PPMs) as part of Maintenance of Certification (MOC).

Methods

Descriptive study of all hypertension PPMs completed by family physicians from July 2006 to 2013. Descriptive statistics characterized physician demographics and quality outcomes; linear regression determined characteristics associated with improvement.

Results

In total, 7,319 hypertension PPMs were completed by family physicians that had a mean age of 47.9 years and 14.2 years of practice experience. Most (52.4%) chose lipid control as their quality improvement (QI) focus. Performance on all quality measures improved except mean low‐density lipoprotein (LDL) and high‐density lipoprotein (HDL) cholesterol values; however, percentage of patients with LDL < 130 mg/dl improved. Improvement was seen in blood pressure control (87.4% to 92.6%, p < .05), low sodium diet counseling (74.1% to 92.7%, p < .05), and exercise counseling (82.4% to 94.4%, p < .05). In regression models, no variable was consistently associated with improvement.

Discussion

Family physicians improved the quality of care for patients with hypertension through MOC. Leveraging MOC across all specialties may become an important support for improving management of conditions that cause considerable morbidity and mortality.

Measuring Hospital‐Wide Mortality—Pitfalls and Potential

Journal for Healthcare Quality -

Abstract

Risk‐adjusted hospital‐wide mortality has been proposed as a key indicator of system‐level quality. Several risk‐adjusted measures are available, and one—the hospital standardized mortality ratio (HSMR)—is publicly reported in a number of countries, but not in the United States. This paper reviews potential uses of such measures. We conclude that available methods are not suitable for interhospital comparisons or rankings and should not be used for pay‐for‐performance or value‐based purchasing/payment. Hospital‐wide mortality is a relatively imprecise, crude measure of quality, but disaggregation into condition‐ and service‐line–specific mortality can facilitate targeted improvement efforts. If tracked over time, both observed and expected mortality rates should be monitored to ensure that apparent improvement is not due to increasing expected mortality, which could reflect changes in case mix or coding. Risk‐adjusted mortality can be used as an initial signal that a hospital's mortality rate is significantly higher than statistically expected, prompting further inquiry.

Adolescents Are Less Satisfied with Inpatient Psychiatric Care than Their Parents: Does It Matter?

Journal for Healthcare Quality -

Abstract Objective

Patient satisfaction is a commonly used measure of healthcare quality. Limited research exists among psychiatric inpatients, especially adolescents, who pose unique challenges. This study sought to (1) concurrently assess adolescents’ and parents’ satisfaction with treatment and (2) compare their perspectives’ association with treatment outcomes.

Methods

This exploratory study assessed discharged adolescents from a specialty psychiatric hospital. Adolescent patients and parents completed the Perceptions of Care survey (POC), a measure of patient satisfaction. Patients also completed the Youth Self‐Report measure, while parents also completed the Child Behavior Checklist—both are used as measures of mental health treatment outcomes.

Results

Adolescents and parents gave favorable overall ratings of care. Adolescents were more critical than their parents, and there was little agreement between them. Adolescents’ ratings on the POC frequently related to outcomes, whereas parents’ ratings rarely did.

Conclusions

Ratings of satisfaction with adolescent healthcare can vary depending on whether patients or caregivers are assessed. The discrepancy between them contains value: adolescents’ perception may be a better gauge of treatment outcomes and may affect treatment adherence. Future research should examine adolescent‐specific concerns in the context of satisfaction with care and relate them to longer term treatment outcomes.

Catastrophic Medical Malpractice Payouts in Spain

Journal for Healthcare Quality -

Abstract

Patient safety and professional liability are major concerns worldwide. Despite the pervasive influence of catastrophic malpractice payouts, little is known about the specific characteristics and the overall relevance and characteristics of these payouts, especially outside U.S. borders. Five hundred fifty claims led to a payout among 2,236 claims from January 1, 2004 to December 31, 2010, in Catalonia (Spain). We analyzed data on patient, provider, and claim characteristics. Accordingly to our sample, Spanish catastrophic payouts (SCP) were defined as payouts over €200,000, which was found in 32 cases (5.8%). Diagnostic errors and patient death were not as relevant as previously reported. However, it is remarkable that the literature emanating from different countries shows similar trends besides contextual differences: patients suffering minor injuries are not likely to receive a catastrophic payout, catastrophic payouts are associated with patient age less than one; SCP are most associated with anesthesiology and resuscitation, general surgery, and obstetrics and gynecology; and SCP were more likely to occur when a case went to trial compared to when a case was settled out of court. Studies, such as this, provide a wider picture of the medical liability worldwide reality and helps avoiding isolated discourses.

Pages

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