Specialized cardiac hospital in Indianapolis to be completely digital

By Jerry Zeidenberg

INDIANAPOLIS – North America’s first all-digital cardiac hospital – meaning no paper records or diagnostic film will be used – is scheduled to open its doors in Indianapolis early next year. Instead of keeping and shuffling hard copy records, all documents and images at the new, US$60 million facility will be created, stored and transmitted by using computerized equipment and networks.

“We believe this will be the best way of providing care for the future,” said David Veillette, chief executive officer of the new facility, called the Indiana Heart Hospital.

“What we have today [in most hospitals] is a tremendous amount of paper,” he said. “What we want, on the other hand, is to get more information to doctors and nurses at the bedside, so that they don’t have to chase things in different parts of the hospital.”

Veillette said there won’t even be any nursing stations at the new hospital, because, “we don’t want nurses to go back an forth to a station, we want them at the bedside.”

He commented that digital technologies and new methods of working are expected to lead to care that’s both more efficient and more effective.

“The aging of the baby boomers means we have to find more efficient ways to take care of three times as many patients, with staffing levels that will be decreasing,” said Veillette. “The only way to do that is with information technology.”

The hospital will have 88 patient beds, 32 outpatient rooms, four surgery suites, six cardiac catheterization labs and a cardiac emergency department. It will offer a wide range of services, from open-heart surgery to emergency care, rehab, screenings, research and education.

Wired and wireless computerized systems are expected to save a great deal of time and trouble by delivering patient information right at the bedside. “At the stroke of a key, I will have the patient’s history, I will have a list of his or her medications, I will know his or her allergies,” said Dr. Michael Venturini, cardiologist and chief medical officer of the Indiana Heart Hospital. “I will be able to review not just reports, but actual images of echocardiograms, of EKGs, of cardiac catheterization films. It will make me and all my peers better physicians.”

Dr. Venturini said that caregivers will be able to document, write orders and review at the point-of-care. “That is critically important,” he noted. “By doing that, we will enhance quality and safety.”

For example, physicians and nurses will be able to quickly check whether patients are receiving the correct drugs, in the right dosage. He contrasted this with current procedures in many hospitals, where information gathering is a hurdle, and obtaining a paper medical record or retrieving a diagnostic film can take several hours.

What’s more, the software will allow the hospital to track and analyze its own performance. “We’ll have real-time metrics, and we’ll be able to look at clinical performance, staff and costs,” said Dr. Venturini. “For example, we can learn how good the hospital is at coronary bypass operations, or how successful individual physicians are at placing stents. We can use this information to improve the performance of the hospital and the delivery of medicine.”

To create a complete digitized facility, the Indiana Heart Hospital is working in close collaboration with GE Medical Systems, of Milwaukee, Wis. While in the past, GE Medical has been chiefly known as a supplier of diagnostic imaging equipment such as X-ray systems, CTs and MRIs, more recently it has been expanding the scope of its offerings.

In this instance, it will provide a complete clinical information system that’s integrated with diagnostic imaging and patient monitoring systems.

The technology that’s being installed includes the GE Centricity Information System, which is said to be an enterprise-wide clinical information system that integrates patient data – such as images, waveforms and medical history – from every care area of the hospital into a single electronic record that can span a patient’s entire lifetime.

What’s more, GE will also supply leading-edge diagnostic technologies, including an all-digital cardiovascular imaging system, called the GE Innova 2000. It will also provide gender-specific ECG technology to test women’s heart waveforms, and a system that conducts 30-minute cardiac exams via MRI technology.

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OHA launches national e-learning initiative for healthcare

By Jerry Zeidenberg

TORONTO – The Ontario Hospital Association hopes to improve the delivery of education and training in the healthcare sector with the launch of Healplex, a web-based e-learning service. Healplex organizers say the on-line courseware and management software will dramatically reduce the cost of on-going education for hospitals and make continuous learning much easier for employees.

“There’s been an explosion of information in healthcare, and it’s a real challenge for hospitals to keep up with it,” said John Ferguson, senior e-commerce advisor for the OHA and one of the key developers of Healplex.

Along with the OHA, the Toronto-based Change Foundation is a co-creator of Healplex.

Traditionally, to upgrade the skills of personnel, hospitals have sent nurses, doctors, administrators and technologists on half-day or full-day training courses. This has often proved difficult, as the medical centers are then left scrambling to find replacements for these employees.

Moreover, training can be expensive, and educational costs have piled up for rural hospitals, which often need to send staff to urban centers for skills upgrades. In these cases, they must also foot the bill for transportation, hotels and food.

By contrast, most Healplex courses take 90 minutes or less to complete and can be performed on a plain-vanilla computer with web access. Employees can squeeze the work into spare hours – day or night. “It’s available to them around the clock, and because it’s on the web, it can reach anyone, anywhere, anytime,” said Ferguson.

To start, Healplex has gained a source of high-quality content by teaming up with Healthstream Inc. of Nashville, Tenn., the biggest provider of on-line healthcare training in the United States. Healthstream supplies e-learning services to over 1,200 U.S. hospitals and has developed 3,000 hours of web-based courseware, covering a wide range of medical, legal and administrative topics.

For its part, Healplex is working with experts here to ‘Canadianize’ the content, making sure that it covers Canadian issues and uses familiar terms.

As it goes along, Healplex also plans to work with Canadian hospitals, technology vendors and other enterprises to create new courseware, which in turn could be marketed to healthcare providers across Canada and the United States. This entrepreneurial aspect of the program offers a revenue stream to Canadian hospitals, and a way of further developing the high-tech skills of employees.

Officially launched last November, at the time of the OHA convention in Toronto, Healplex has now validated 27 Healthstream courses to ensure that they meet Canadian standards. This initial set of courses is aimed primarily at nurses and administrators, and includes topics such as:

• Preventing slips, trips and falls.
• Security and workplace violence.
• Standard precautions – blood and body fluids.
• The art of customer service.
• Working with hazardous chemicals.
• Carpel tunnel syndrome.
• Latex allergy overview.
• Lifting and transporting patients.
• Performance improvement in the workplace.

And others.

“We’re bringing credible experts to review the content and validate the courses for the Canadian market,” said Heidi Bilas, content development manager for Healplex. She has been seconded from Baycrest Hospital, where she was telehealth site manager.

In terms of costs, a hospital could provide 1,000 employees with access to the current Healplex package of 27 courses for about $50,000 annually. That’s considerably lower than traditional forms of training.

“E-learning typically amounts to one-third to one-half the cost of on-site education,” said Ms. Bilas. “It’s much more economical.”

Ferguson explained that Healplex not only includes courseware, but also offers a student and instructor management system. Administrators can track course completion rates, view marks obtained by students, post messages, and massage the data in various ways.

Students can also obtain access to their own transcripts.

Ferguson noted that web-based education isn’t meant to replace classroom training and other forms of teacher-student instruction. Instead, it’s another means of providing education. “Healplex is complementary to face-to-face training, which will always be important,” said Ferguson.

Healplex has been holding meetings across Ontario, promoting the new service to hospital managers. This year, it expects to sign-on two to three dozen hospitals across Canada. Information about the new company and its services can be found at www.healplex.com

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Using EMR to practice evidence-based medicine via a virtual library

By Tim Tripp, B.Sc, MLIS, and Matthew W. Morgan, M.D., M.Sc.

According to a recent PriceWaterhouseCoopers survey, one hour of inpatient care and emergency care generate 36 minutes and one hour of paperwork, respectively! Multiply the time clinicians should spend on patient care by the number of hours they must spend on paperwork and it’s easy to understand why keeping up with reading quickly falls to the bottom of their priority lists.

The hospital library has always played an important role in clinical decision support, helping clinicians stay up-to-date on the latest medications, procedures and other advances aimed at improving the quality of patient care. However, faced with hundreds of medical articles published weekly, no simple way to access them and no time for anything short of quick glance, the average clinician finds keeping up with evidence virtually impossible – especially if doing so requires visiting the hospital library.

But one large Canadian teaching hospital group has figured out how to help clinicians stay on top of things. By licensing content from publishers and library consortia and co-licensing material with the University of Toronto, the University Health Network (UHN) of Toronto has created a Virtual Library to provide a core of biomedical information resources for its clinical community.

The Virtual Library Project: UHN embarked on its innovative Virtual Library project in 1999. The project’s purpose was twofold: To provide a seamless, single-interface access to all library resources irrespective of the resources’ or users’ physical location, and to integrate the resulting virtual library into UHN’s electronic patient record (EPR).

By licensing content through direct deals with publishers, negotiating with library consortia and taking advantage of co-licensing arrangements with the University of Toronto, UHN is able to provide a core of evidence-based information resources for the clinical community. Implementing a Web-based interface to these various resources on the hospital intranet that is also integrated into the electronic patient record ensures wide exposure and easy, integrated access to these crucial knowledge resources.

UHN’s four-step implementation process began with an inventory of UHN’s resources and services. Next, UHN benchmarked other healthcare organizations and university libraries. Then, the library and intranet staff developed an initial design and made it available to a select group of users. Finally, after incorporating feedback from test users, developers worked with UHN’s Public Affairs office to roll out the Virtual Library in the spring of 2000.

The Technological and Information Foundations: Unquestionably, the Virtual Library is an idea whose time has come. But it is just evolving from idea to reality because it rests on two equally evolving technologies, the Internet and the electronic patient record.

Books have been around since 2800 B.C.; libraries since somewhere around the 5th century B.C. The Internet? About 20 years. And while it has become the vehicle of choice for access to information, the Internet cannot effectively deliver such resources as biomedical databases and electronic full-text journals demands without an access-driven infrastructure. Recognizing this, UHN recently implemented a major infrastructure upgrade, providing Internet/intranet access to more than 4,500 desktop PCs across its three hospital sites to create the technological foundation for the Virtual Library.

To create the foundation, UHN had to integrate the Virtual Library into its EPR. UHN’s first step was to implement a Web-based interface to the hospital Intranet via its EPR solution, Patient1 from Per-Se Technologies. Patient1 provides access to such core biomedical databases as Medline, Ovid and CINAHL; evidence-based full text collections, such as the Cochrane Database of Systematic Reviews and the ACP Journal Club; and more than 1,400 full-text electronic journals, electronic texts, interactive request forms and quality Internet links selected by library staff.

The next step is to bring the Virtual Library and the EPR even closer, truly integrating clinical decision support into clinical workflow. Primarily, physicians, nurses and other clinicians access the Virtual Library from Patient1. Using Java and XML, UHN is creating interfaces that can retrieve relevant, evidence-based content directly from diagnostic and order entry screens within the patient record. So far, 18 alerts – accessible directly from the EPR and triggered at data entry – have been created and more are in the works.

Survey: But are clinicians using the Virtual Library? According to the numbers, yes. According to ongoing use analysis:

• 400 users access the Virtual Library each weekday. The three physical libraries average 550 “users” per day, 3,500 database searches per month. Fifteen percent of use happens outside physical library hours.

• 65 percent of users access databases, while 25 percent peruse electronic journals

And what do clinicians really think about the Virtual Library? Results of a recent survey of staff physicians and residents showed:

• 95.7% believed the Virtual Library saved them time

• 96.8% said it helped them make clinical decisions

The evolution from cuneiform to HTML may have been a slow one, but UHN’s Virtual Library is ensuring that it won’t take nearly as long for clinicians to have the right clinical information, right when and where they need it to make the right decisions.

About UHN: Comprising Toronto General Hospital, Toronto Western Hospital and Princess Margaret Hospital, the University Health Network is the primary teaching hospital for the University of Toronto. The 1,000-bed network employs 10,000 staff and averages 42,000 admissions, 560,000 ambulatory care visits and 66,000 emergency visits annually.

Tim Tripp, B.Sc, MLIS, is Senior Project Manager, Clinical Decision Support, Shared Information Management Services, University Health Network. Matthew W. Morgan, M.D., is an assistant professor, Department of Medicine, University of Toronto, a general internist at UHN and director of healthcare informatics, Per-Se Technologies.

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Emphasis on training and certification transforms IT at Toronto’s Baycrest Centre

By Stephen Tucker

When I was hired in 1999 to manage Baycrest Centre’s Systems and Operations Group, I saw huge opportunities as well as significant challenges. In terms of challenges, the new team comprised six people, most of whom did not have much IT experience. Our network, which supported 700 users, went down at least twice a day. Users calling our help desk typically got voicemail. We had three different flavors of Novell and system patches were everywhere. Staff turnover was high.

The opportunities included working for one of the leading healthcare facilities of its kind in Canada, and helping to build its IT operations.

Now the system is up 99.913 percent of the time. We effectively field more than 50 help desk calls a day, and there is a live human being at the help desk. Staff turnover is low and the Systems and Operations group, now numbering 14, is comprised of enthusiastic, trained, and certified IT specialists. We have a waiting list of people wanting to join the team from other departments within the facility. Centre management increased the IT capital budget significantly last year and salaries within the department have risen. We have plans to become an out-sourcing system and support service provider to other geriatric facilities in Canada.

This is the story of the transformation of the Baycrest Systems and Operations group. I present it as an illustration to other department managers of the transformational power of training linked to IT certification.

By way of background, Baycrest Centre provides a wide range of residential, day programs, and specialized services for the elderly of the greater Toronto area and is a recognized leader in geriatric research. The centre offers programs on-site and in the home, as well as providing individuals and families with counseling, education, and referrals.

The centre is a fully affiliated teaching institution with the University of Toronto. More than 100 Baycrest staff members are full, associate, or assistant professors at the university, and more than 500 students from universities, colleges, high schools, and technical institutes receive educational training at Baycrest each year.

Baycrest’s IT department is comprised of two groups – applications, and systems and operations. The Applications Group develops new applications, particularly around business and healthcare systems. Systems and Operations is responsible for telephony, hardware, software, and networking – approximately 1,000 servers, PCs, and printers are on our Windows 2000 network. We serve approximately 700 people. Today, six people staff the help desk while another eight are network administrators.

When I started in 1999, I prioritized the problems I wanted Support and Operations to tackle first. The most important problem was low network reliability. Uptime had to be improved. The second biggest problem was that the staff overall did not have a framework for problem solving. Thirdly, we needed to standardize hardware, software, and protocols and eliminate as much as possible variation in the network. Unfortunately, variation in an IT environment produces more complicated, time-consuming problems. Fourthly, we needed to begin to build the confidence and trust of our user community.

Options and implementation: One option we explored to solve some of our problems was to partner with a leading hardware supplier and have them overhaul the entire network. We rejected this option based on the projected downtime we’d experience and the high cost. A second option was to outsource IT support. We felt the cost of this option was prohibitive.

A third option was to build a comprehensive solution from within – train and motivate our way toward high uptime and user confidence. We felt that this was our most effective option. Our people wanted to do a good job; they simply needed the tools. And if we were creative, I felt we could solve our problems cost effectively. There are so many options for training. I felt I needed to narrow my search down to the fundamentals.

I was familiar with the Computing Technology Industry Association (CompTIA) A+ and Network+ certifications and decided to explore these to a greater degree. I learned that the A+ certification is appropriate for a computer service technician with six months experience and covers a broad range of hardware and software technologies. Also, it’s supported by all the major players in the computing industry, including Microsoft, IBM, HP, Compaq, and Intel. Network+ measures the technical knowledge of networking professionals with 18-24 months experience. Earning the Network+ certification means that the individual possesses the knowledge needed to configure and operate a variety of networking products.

I decided to pursue these options for my team. Training for A+ and Network+ would give my team a comprehensive knowledge base. Another consideration was that training linked to certification would give me an objective means of knowing that the team shared a common base of knowledge. It would also make it easier for the team to talk with one another and collaborate when solving problems. They would have a shared understanding of terms and procedures.

Importantly, there was a wealth of course materials and options to choose from for A+ and Network+ training. We began by buying, very cost effectively, training manuals written by New Riders Publishing at a local Costco department store. We set up a test lab complete with a 10 PC network by using old PCs. We set aside three lunch hours a week for study. The department provided lunch.

Team members urgently wanted to learn and to become IT professionals. We had volunteers who each were responsible for leading a discussion on a chapter from the A+ and Network+ manuals. Additionally, each person went thought the manuals on their own. Essentially, we opened a new door for them, and they ran through with enthusiasm.

I went through the training alongside the team. I felt that it was extremely important to establish trust by showing the group that we were all in this together. Study topics gave us an additional opportunity to talk about problems we were having with the network and ways of solving them. As we went through the chapters, we started to identify the various layers of technology and how they interact. I could see light-bulbs going off in peoples’ minds as they saw how all of this impacted our network and the issues we were struggling with.

In total we invested in 40 weeks of study. The cost for the training, including manuals and tests, averaged $250 per person. We bought test vouchers in quantity at a good rate which helped keep costs to a minimum. We spent about $5,000 on lunches. The first time through only one person earned their A+ certification. The others maintained their enthusiasm, and over time we have had 100 percent certification of the team for both certifications.

Now, if a Baycrest employee from an outside department wants to join our team, we ask that they become certified first. We provide them with a self-study course on CD from Learning Tree International. We pay for the exam only after they pass it.

Lessons learned: One of the things that is most important in a transformation like this one is the department manager’s firm commitment to the process. We went through periods where daily problems put a stop to the lunch sessions. We got back to our learning regimen as soon as possible, but the interruptions delayed us. In hindsight, I’d not let daily problems slow down training.

Asking vendors to share their expertise is a great strategy for continuous improvement. Vendor presentations provide a good picture of where vendor specific technology is going. These presentations also spark good ideas. On average we now have a vendor presented lunch-and-learn session twice a month.

Results: When I started, average network uptime was 98 percent. This means that the network was down for a week each year. At the time this article is being written, we have uptime of 99.9913 percent – only 45 minutes of downtime a year. Our goal is 99.999 percent uptime. User trust has gone way up as a result.

Team members have improved their problem-solving skills immensely. They are resisting the impulse to jump to the easiest or most obvious conclusion. They instead consider the possible root causes. The result is that we are solving user problems twice as fast now compared to 1999.

The positive impact on employee turnover has been amazing. We went from close to 50 percent annual turnover to less than 5 percent. This has had a huge impact on the cohesion of the team and on our overall productivity. Time lost through illness is also down significantly.

We have become proactive professionals rather than predominantly reactive technicians. CompTIA A+ and Network+ certification supported this. Training for the certifications help us organize and acquire the right kinds of knowledge. Certification instilled pride and boosted confidence. We now have many examples of people going above and beyond, where we did not before. It is truly wonderful to see and to experience the impact on department level productivity and morale.

Others have recognized how far the team has come. In fiscal 2000, roughly 70 percent of Baycrest’s annual capital budget was dedicated to upgrading IT infrastructure – the most ever committed at one time. We were told that this was a direct result of the improvements we were making, the trust we were earning, and the positive impact on operations. The upgrades solved many of the hardware and software variation issues that existed at the start of the transformation.

Today, we are about to become a resource for other eldercare facilities and extend the mission of Baycrest Centre. In an amazing turnabout, other healthcare providers are sending benchmarking teams to Baycrest to see how we are performing this magic. The road to transformation was not easy or straight. But the journey has been very much worth it.

Stephen Tucker is Acting Director, Information Technology, Baycrest Centre for Geriatric Care in Toronto.

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Robotics, bar-coding used to improve patient safety with medication

By Dianne Daniel

Grand River Hospital is tackling the five “rights” of medication administration head on – ensuring the right drug in the right dose gets to the right patient via the right route at the right time – following the launch of an automated drug dispensing system earlier this year.

Since mid-February, all units at the 500-bed facility in Kitchener, Ont., have been receiving unit dose inpatient medications from a centralized robotic drug distribution system and, according to director of pharmacy Cathy Kan, the roughly US$1 million investment in technology is actually quite affordable for the improvement in quality it’s delivering.

“People may tend to say, How can I afford it?, when really the question is, How can I afford not to have it?” says Kan.

In choosing the ROBOT-Rx system from McKesson Automation, represented in Canada by Medis, Grand River becomes the second site in Canada to use the technology since Toronto’s Sunnybrook & Women’s College Health Sciences Centre brought it onboard five years ago.

Whereas manual unit dose dispensing – performed by human eyes and human hands – carries an average error rate of three in 1,000, the robot using barcode reading technology improves that to one in 37 million, says Kan.

At Grand River, unit doses (enough medication for a 24-hour period per patient) are barcoded and then “picked” by the robot, which receives a computerized order and reads the barcoded information on the drug to ensure accuracy.

If a drug has expired, it will be rejected. Once picked, drugs are sent to the appropriate floor of the hospital through a system of tubes (similar to those used for cashier money drops by some retailers), capable of transporting three litre bags or seven kilograms of medication. According to Kan, the picking time is four seconds and average transport time is 23 seconds.

At Sunnybrook & Women’s, the same robotic technology is used, but instead of the tubes, drugs are placed in a special drug-dispensing cart that is then taken to the various wards. The cart, standing about four feet high with a computer on top, has drawers that will open to dispense a drug once a nurse enters the patient information on the screen.

Though neither hospital has statistics to indicate the level of medication error actually occurring at their facilities, both Kan and Sunnybrook & Women’s director of pharmacy Tom Paton, say recent evidence coming from the U.S. was enough to prompt them to take action.

The most talked about statistic is one from the American Institute of Medicine that indicates between 44,000 and 98,000 patients die each year as a result of medical errors.

Approximately 7,000 of those deaths are the result of medication error, says David U, president and CEO for the Canadian Institute for Safe Medication Practices (ISMP), a non-profit, independent organization based in Richmond Hill, Ont., which promotes the use of technology to reduce or prevent medication mistakes.

“We extrapolate that to be about 700 deaths in Canada,” says U. “We don’t have any hard number to support that, but we will down the road. Our focus isn’t so much on the numbers, but more on the identified problem areas we’re trying to address,” he adds.

For example, research has shown that up to 49 percent of medication errors actually occur at the ordering stage due to reasons such as illegibility, incompleteness, or a lapse of clinical judgment, he says. The U.S. is responding by legislating the use of computerized physician order entry software and U would like to see a similar push for use of the technology in Canada, as well.

However, Ron Dunn, vice-president of McKesson Information Solutions’ Canadian operations, sees a great deal of reluctance to adopt physician order entry systems. “In the U.S., most of the hospitals can compel the physicians to adopt new technology because the physician is paid by the hospital. Canada’s not the same,” he says. “A lot of their reluctance over the past five years has been because we’ve taken systems designed for other clinical people and tried to make them applicable to the doctor. Frankly, that was the wrong approach and every vendor has had to either re-engineer their products or design entirely new systems.”

Such systems, like McKesson’s Horizon Expert Orders, can aid physicians by supplying clinical decision support and evidence-based data by listing potential drug orders after a specific condition is entered, along with patient information such as latest laboratory values, radiology results or patient demographics, to ensure the drug prescribed won’t have an adverse effect on the patient.

Another area ISMP Canada would like to see addressed is the administration phase – the actual act of administering the drug to the patient – where studies have shown roughly 23 percent of errors take place. While robotic systems help to ensure the right drug is selected, companion technology can be used on the nursing floors to eliminate additional possibilities for error, says U.

Using handheld devices on a wireless network, for example, nurses could take the drug picked by the robot, scan it, scan their hospital identification badge and then scan the patient wristband – all of which would be barcoded with pertinent information that would then be fed to clinical software to ensure no errors are being made. Grand River has set a goal to begin implementing such devices within 12 months, while at Sunnybrook & Women’s, Tom Paton would also like to follow suit.

“This is where we start to piggyback on the notion that these medications are barcoded,” he explains. “So you can use point-of-use scanning devices that will check the package content to be sure it’s the drug you talked about, scan the patient to be sure it’s the right patient and then scan the (nurse) so there’s a record of who gives the drug.”

In the five years since implementing McKesson’s robot, Sunnybrook & Women’s has been pleased with its performance, says Paton. However, no studies have been done to indicate whether or not fewer errors are being made. “We went into this with a view that it would be more efficient and that we could be spending pharmacists’ time doing other functions that serve the patients better,” he said.

In particular, the pharmacist’s role at Sunnybrook & Women’s has evolved into more of a cognitive one, including consulting with physicians and nurses over the selection of a drug. They are also able to accomplish more without hiring additional staff. “I believe the acuity of care and the resource intensity for patients has increased tremendously in the last three to four years,” says Paton. “So, we’re able to do a little bit more with the same number of staff, and I don’t think we could get there without some of this high tech.”

Right now, with only a handful of Canadian hospitals looking at technology as a means to reduce and prevent medication error, two of the biggest challenges are education and funding, says U. “A lot of people would like to do patient safety things, but they don’t have the tools to allow them to systematically implement some of these changes.”

To help, ISMP Canada is providing self-assessment tools as well as tool kits to assist in making changes, and has partnered with the federal government to help get efforts under way. It has also created a Web-based system to facilitate the reporting of medical errors in a culture of non-blame. “The interest is there, but unfortunately the dollar is not available yet,” says U. “Leaders need to take a hold of the fact that this is not a small thing that the individual practitioner can do. I think they need to recognize the priority of patient safety, promote it and genuinely work towards some of these solutions.”

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