1 P NNSYLVANIA ASSOCIATION OF LIC NS D MIDWIVCS Testimony by Vivian Lowenstein, CNM, MSN Pennsylvania Association of Licensed Midwives American College of Nurse-Midwives May 3 1,2007 Before the Professional Licensure Committee Public Hearing on House Bill 1255 Regarding Prescriptive Authority for Midwives My name is Vivian Lowenstein and I am a certified nurse-midwife and licensed certified registered nurse practitioner in the Commonwealth of Pennsylvania. I am the president of the Pennsylvania Association of Licensed Midwives, which is a statewide network of licensed midwives and chapter chair of the American College of Nurse-Midwives, Chapter 4, Region 11. Thank you for the opportunity to speak with you today about Prescriptive Authority for Nurse-Midwives (HB 1255). We would also like to thank all of the individuals who have met with us, who have sought to understand our role as midwives to provide access to care for women and who have been part of bringing this bill to hition. We applaud Governor Rendell for putting forward the health care initiative, "RX for Pennsylvania" which has identified the changes needed to provide better heath care to our citizens. The title of his proposal is not only relevant for citizens of the Commonwealth, but also for midwives who have been working to eliminate barriers to our practice, most importantly to gain prescriptive authority. My hope today is to help you better understand why prescriptive authority is important for midwives, the women that they serve and the crisis we are now experiencing concerning women's health care and access to care in the Commonwealth. PRESCRIPTIVE AUTHORITY FOR CERTIFIED NURSE-MIDWIVES Remarkably, Pennsylvania is the only state in the nation where nurse-midwives do NOT have prescriptive authoritv. As I mentioned previously, our state is leading the nation in educating nurse midwives but then not allowing them to practice to their full scope of practice. I find it ironic that I would be able to prescribe medication under my Certified Registered Nurse Practitioner license, but not under my Midwifery licens~ven though students in both of these disciplines receive the same pharmacological training, in the same classes, at the University of Pennsylvania. Our educational programs, like others in the U.S., prepare nurse-midwives in pharmokinetics and pharmacology and the decision-making to prescribe medications safely within the midwives scope of practice. Our scope of practice is well defined in our national standards, in our educational programs and in our state regulations. Graduates of nurse-midwifery programs are required to sit for a national certifjling exam that in part tests the knowledge, decision-making and safety of pharmacology and prescribing.
2 Although the licensed midwife has the knowledge of what medication to safely order and can intelligently discuss this with the patient including educating her about side effects, risks and benefits, in Pennsylvania a doctor must sign the prescription. A DAY IN THE LIFE OF A NURSE-MIDWIFE I'd like to take a moment to offer some insight of how CNM's practice and of how prescriptive authority affects the care that we give and the women that care for. There are many possibilities of how a midwives day may be scheduled, whether they are on call for women in childbirth or seeing patients in the office. I'll describe a typical day 4 the office. My schedule for patients is from 8:30 to 4 PM. and I'll be scheduled for approximately patients. Some of the women will be new GYN clients, new pmgnancy visits, annual GYN visits and prenatal visits. Many young women who come for my care would like medication to control irregular menstrual cycles, distressing pain associated with their periods, or contraception. I talk to the woman and do a complete health history to identify the patient's health status and any risk factors. I talk to her about the therapeutic possibilities ranging from no medication, to behavioral and other interventional changes, to the use of certain medications. I ask the woman what she feels most comfortable doing and if the likely treatment is to include a medication. I explain the benefits, risks, and potential side effects. I then do a 111 physical exam which includes a breast exam and teaching her how and when to do a self breast exam. I prepare her for and gently do a pelvic exam, which may include a PAP test, sexually transmitted infection screening and internal exam. When the exam is done I reassess with the women what medication is safe for her to take for her specific nee& The entire visit takes between minutes for a new patient. I write the prescription. But I can't sign it, I then need to find my collaborating physician to sign the prescription. I may need to wait for the physician to finish an exam with a patient in another room. The physicians are often "double-booked" seeing a patient every 5-7 minutes or seeing high-risk patients which take more time. The patient also has wait, or come back for the signed prescription. There are times when I call the prescription in to a pharmacy after the physician has signed or given me the okay to do so. The doctor signs the pmscription and may have never met or examined the patient. The physicians we practice with know our scope of practice, have signed and agree with our written collaborative agreement and trust that we are consulting and prescribing safely. All of this takes time, for the physician, for the patient and for the nursemidwife. In the meantime all my scheduled patients are waiting. This pattern may occur all day, and includes writing prescriptions for prenatal vitamins, iron supplements for anemia, contraceptives, antibiotics for sexually transmitted infections, treatment for common vaginal infections, urinary tract Sections, and postpartum depression (And we are not able to order pain relief for labor and delivery). You should know that the physicians I work with don't understand why they have to sign our prescriptions. They are worried about their liability and many physicians are refusing to work with midwives because of this. This is aflfecting access to care for women in PA.
3 AMENDMENTS FOR HB 1255 I'd like to now address some specifics of HB ) Midwives in Pennsylvania are licensed as Midwives, not as Nurse-Midwives. We would like language of HB 1255 to be consistent with our current regulatory-language to use the tern midwife. 2) There is language in HB 1255 that we believe was an oversight and needs to be amended. Section 2-C "Acts in collaboration with a physician as set forth in a written agreement which shall at a minimum identify the categories of drugs from which the nurse midwife may prescribe or dispense and the circumstances under which the collaborating physician will personally see the patient" should be deleted. Identifyrng categories of drugs is another way of establishing a formulary. Formularies tend to be out of date almost as soon as they ate written. Pharmacology is rapidly changing and new medications, uses of medications, and withdrawal of medications, may occur on a day to day basis. A formulary developed one day could be out of date in a very short period of time. The current regulations about our collabo~ative agreements and written protocols provide a framework of what medication categories fall within a midwives scope of practice as agreed to by the midwife and her collaborating physician. Our current regulations also identify how licensed midwives collaborate, co-manage, or refer patients to our collaborating physicians. This language has served the public well for over 20 years. "Personally seeing the patient "could be result in double billing for a visit that may not be necessary. The reasons for a physician seeing a patient are covered very well in the collaborative agreement between the midwife and the physician. This clause could be interpreted in many ways and thus should not be included in legislative language that is intended to provide clarity. Any language that includes "supervision", "under the overall direction", "circumstances under which the collaborating physician will personally see the patient" are restrictive and should be removed. Collaboration is a term that we need to continue to use, which is a relationship of mutual respect between health care providers "to deliver health care services with each contributing their expertise within the scope of their license, education and training". When health care providers work together our clients receive integrated, high quality and safe care. 3) At the end of HB 1255 Section 2, it says that "The State Board of Medicine shall promulgate regulations to implement the amendment of section 35 of the act within 18 months of the effective date of this act." There is no need to take 18 rnontbs to promulgate regulations concerning prescriptive authority for nurse-midwives. I suggest that this be amended to, 60 days. It is my understanding that when HI passes in the House that this language will preempt regulatory language.
4 Our current regulations that relate to prescriptive authority, read: The midwife is authorized and required to do the following: (1) Engage in midwifery practice as defined in (relating to definitions), as further provided for in this subchapter and in accordance with the ethical and quality standards of the profession as required in section 41(8) of the act (63 P. S (8)). (2) Maintain a midwife protocol and collaborative agreements, and make them available for inspection by clients and the Board upon request. (3) Prescribe medical, therapeutic and diagnostic measures for essentially normal women and their normal neonates in accordance with the midwife protocol or a collaborative agreement, or both. (4) Administer specified drugs as provided in collaborative agreements or as directed by a collaborating physician for a specific patient and, if specifically authorized to do so in a collaborative agreement, relay to other health care providers medical regimens prescribed by the collaboratiag physician, including drug regimens. To update midwifery regulations would take 1 or 2 Board of Medicine meetings (30-60 days). A few words need to be added to our current regulations in addition to the educational requirements in this bill. The Board of Medicine should have no reason to take a year and a half to rewrite regulatory language. It has already been written in this bill. The Board of Medicine has been charged to make sure that the citizen's of the Commonwealth receive safe health care. Licensed midwives want to be accountable for their decisions and their practice. We believe that in the interest of safety and integrity, licensed midwives should be responsible for the decision-making of writing and signing a prescription. THE CRISIS OF MATERNAL CHILD HEALTH IN PENNSYLVANIA We are now experiencing a crisis in PA. Fourteen hospitals in the Philadelphia region are no longer providing maternity care, with one (Chestnut Hill Hospital) on the verge of closing. In other areas of the state, hospitals have also stopped providing maternity care. Women must drive to other counties (sometimes an hour away) to deliver their babies, some OBIGYN practices are not accepting medical assistance patients, OBIGYN's are deciding only to practice GYN, OBIGYN physicians are leaving the state, licensed midwives are loosing their jobs, and many are not able to contract with collaborative physicians and are being denied access to hospitals. It is difficult to recruit out of state OBIGYN's or, licensed midwives to come to PA. Why? Malpractice premiums for midwives and OBIGYN's are unaffordable. Reimbursement rates by third party insurers and medical assistance are too low. And when a woman is uninsured there is no reimbursement for care. Our lgws are restrictive when it comes to clinical nurse specialists, nurse practitioners and licensed midwives. We need to allow ALL health care providers to deliver care within their full scope of practice and encourage providers to work together. The turf battles among health care providers only hinder the access to care for the citizens of our state.
5 We need to stop this wave of hospital closures, of health care providers leaving the state, of restricting the practice of competent, safe and qualified health care providers, of the unaffordable of malpractice insurance premiums. The time has come for Pennsylvania to meet the standards of care elsewhere in America and avert the poor outcomes that will occur if we do take action ww. If we don't take action we will see the consequences of our inability to stop this tidal wave. Women and babies will die. I ask you our legislators who represent the people of the commonwealth to take action. A couple weeks ago I was told by someone in Harrisburg "Don't you know that nothing moves quickly in Harrisburg". I replied "Make this (HB 1255) the fmt''. Let's show the citizens of the Commonwealth that all health care providers, working together without barriers, are needed to provide the high quality, safe and accessible care that they deserve. Thank you for your kind attention. I am pleased to answer any questions you may now have regarding my presentation.
6 DEPARTMENT OF STATE Pt. I Definitions. The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise: ACNM-The American College of Nurse-Midwives. Collaborative agreement-a signed written agreement between a midwife and a collaborating physician in which they agree to the details of the collabodve arrangement between them with respect to the care of midwifery clients. Collaborating physician-a medical or osteopathic medical doctor who has hospital privileges in obstetrics, gynecology or pediatrics and who has entered into a collaborative agreement with a midwife. Midwife-A person licensed by the Board to practice midwifery. Midwife examination-an examination offered or recognized by the Board to test whether an individual has accumulated sufficient academic knowledge with respect to the practice of midwifery to qualify for a midwife license. The Board recognizes the certifying examination of the ACNM as a midwife examination. ~idwifery~ractice-anagement of the care of essentially normal women and their normal neonates-initial 28-day period. This includes antepartum, intraparhun, and nonsurgically related gynecological care. Midwife program-an academic and clinical program of study in midwifery which has been approved by the Board or by an accrediting body recognized by the Board. The Board recogniies the ACNM as an accrediting body of programs of study in midwifery. Midwife protocol-a written document developed by the midwife setting forth, in detail, the scope and limitations of the midwife's intended practice. Authorlty The provisions of this amended under section 2 of the act of April (P. L. 160, NO. 155) (63 P. S ); and sections 8 and 35(a) of the Medical Practice Act of 1985 (63 P. S. $ _ and (a)). Source The provisions of this adopted January 2, effective immediately and applies retroactively to December 31, 1986, 17 PaB. 24; amended May 19,1989, effective May 20,1989, 19 Pa.B Immediately pmceding text appears at serial page (119272). Craw References This section cited in 49 Pa. Code (relating to practice of midwifery) Licensure requirements. The Board will grant a midwife license to an applicant who meets the following requirements. The applicant shall: (1) Be licensed as a registered nurse in this Commonwealth. J Ch. 18 OTHER PRACllTIONERS (2) Satisfy the licensure requirements in (relating to general qualifications for licenses and certificates). (3) Have successfully completed a midwife progam. (4) Have obtained one of the following: (i) A passing grade on a midwife examination. The Board accepts the passing grade on the certifying examination of the ACNM as determined by the ACNM. (ii) ACNM certification as a midwife before the ACNM certification examination was k t administered in (5) Submit an application for a midwife license accompanied by the required fee. For the fee amount see fj (relating to licensure, certification, examination and registration fees). Authority Theprovisions of this amended under section 2 of the act of April (P. L. 160, No. 155) (63 P. S ): and sections 8 and 35(a) of the Medical Practice Act of 1985 (63 P. S and (a)). Source The pmvisions of this adopted January effective immediately and applies retroactively to December 31: 1986, 17 Pa.B. 24; amended May 19, 1989, effective May 20, 1989, 19 Pa.B Immediately preceding text appears at serial page (119272) Biennial registration requirements. (a) A midwife license shall be registered biennially. The procedure for the biennial registration of a r?idwife license is in (relating to biennial registration; inactive status and unregistered status). (b) The fee for the biennial registration of a midwife license is set forth in fj (relating to licensure, certification, examination and registration fees). Authorlty The provisions of this amended under section 2 of the act of April 4, 1929 (P. L No. 155) (63 P. S ); and sections 8 and 35(a) of the Medical Practice Act of 1985 (63 P. S. $ and (a)). Soum The pmvisions of this adopted January 2, 1987, effective immediately and applies retroactively to December 31,1986, 17 Pa.B. 24; amended May 19, 1989, effective May Pa.B. * Immediately preceding text appears at serial page (119272). < Midwife protocol. At a minimum, the midwife protocol shall identify the following: (1) The procedures and routines of care, including specific treatment regimens to be provided by the midwife, by practice area-for example, antepartum, intrapartum, postpartum and nonsurgically related gynecological care.
7 DEPARTMENT OF STATE Pt. I (2) The circumstances under which consultation, co-management, referral and transfer of care of women and newborns are to take place, and the mechanics by which each are to occur. (3) Procedures and routines of care of newborns, including specific treatment regimens, if the midwife manages the care of newborns beyond the time of delivery. Authority The provisions of this amended under section 2 of the act of April 4, 1929 (P. L NO. 155) (63 P. S ); and sections 8 and 35(a) of the Medical hctice Act of 1985 (63 P. S. $ and (a)). Soutce The provisions of this adopted January 2, 1987, effective immediately and applies retroactively to December Pa.B. 24; amended May 19, effective May Pa.B Immediately preceding text appears at serial pages (119272) and (114029) Collaborative agreements. (a) A midwife may not engage in midwifery practice without having entered into a collaborative agreement. (b) A midwife shall only engage in midwifery practice in accordance with a midwife protocol and collaborative agreements. (c) A collaborative agreement shall contain either an acknowledgment that the midwife shall practice under the midwife protocol, or that the midwife shall practice under the midwife protocol as expanded or.- modified in the collaborative agreement. (d) Expansions and modifications of the midwife protocol agreed to by the midwife and the collaborating physician shall be set forth, in detail, in the collaborative agreement. (e) If the collaborating physician intends to authorize the midwife to relay to other health care providers medical regimens prescribed by that physician, including drug regimens, that authority, as well as the prescribed regimens, shall be set forth in the collaborative agreement. Authority The provisions of this amended under se&on 2 of the act of April 4, 1929 (P. L. 160, No. 155) (63 P. S ); and sections 8 and 35(a) of the Medical Practice Act of 1985 (63 P. S. $ and (af) Practice of midwifery. OTHER PRACI'ITIONERS The midwife is authorized and required to do the following: i (1) Engage in midwifery practice as detined in 18.1 (relating to definitions), as further provided for in this subchapter and in accordance with the ethical and quality standards of the profession as required in section 41(8) of I the act (63 P. S (8)). (2) Maintain a midwife protocol and collaborative agreements, and make them available for inspection by clients and the Board upon request. (3) Prescribe medical, therapeutic and diagnostic measures for essentially normal women and their normal neonates in accordance with the midwife proi : tocol or a collaborative agreement, or both. (4) Administer specified drugs as provided in collaborative agreements or as directed by a collaborating physician for a specific patient and, if specifically authorized to do so in a collaborative agreement, relay to other health care providers medical regimens prescribed by the collaborating physician, including drug regimens. (5) Perform medical services in the care of women and newborns that may be beyond the scope of midwifery, if the authority to perform those services is delegated by the collaborating physician in the collaborative agreement, the I delegation isoconsistent with standards of practice embraced by the midwife and the relevant physician communities in this Commonwealth, and the delegated medical services do not involve the prescribing or dispensing of drugs. (6) Refer and transfer to the care of a physician, as provided for in the midwife protocol or a collaborative agreement, or both, those women and newborns whose medical problems are outside the scope of midwifery practice and who require medical services which have not been delegated to the midwife in a collaborative agreement. (7) Review and revise the midwife protocol and collaborative agreements as needed. (8) Carry out responsibilities placed by law or regulation upon a person performing the functions that are performed by the midwife. Authority The pmvisions of this amended under section 2 of the act of April 4, 1929 (P. L. 160, No. 155) (63 P. S ); and sections 8 and 35(a) of the Medical Practice Act of 1985 (63 P. S and (a)). The pmvisions of this adopted January 2, effective immediately and applies retroactively to December 31, 1986, 17 PaB. 24; amended May 19, 1989, effective May 20, 1989, 19 Pa.B Immediately pnading text appears at serial page (114029). Source The provisions of this adopted January 2, 1987, effective immediately and applies retroactively to December 31, 1986, 17 PaB. 24; amended May 19, 1989, effectivemay 20, 1989, 19 Pa.B Immediately preceding text appears at serial page (114029).
8 State Facts CERTIFIED NURSE-MIDWIVES IN PENNSYLVANIA Nurse midwifery in Pennsylvania Certified Nurse-Midwives (CNMs) have been legally recognized in the Commonwealth of Pennsylvania since The first nurse midwifery practice was established in 1964 at St. Vincent's Hospital in Philadelphia. CNM's in Pennsylvania practice in a variety of settings including hospitals, private practices, clinics, freestanding birth centers and at home births. Statistics There are over 200 certified nurse-midwives in Pennsylvania attending 9.4% of all vaginal bihs in the state (2004 Vital Statistics). * CNM's delivered 12.5% of all rural county babies. CNM's attend 30% or more of the births in 12 rural counties (Clinton, Fulton, Hunthgdon, Juniata, Lancaster, Lycorning, Mifflin, Snyder, Somerset, Union, Warren and Wayne). Lancaster County, which only had 4.8% of total live births in Pennsylvania, accounted for 32.4% of all live births in the state delivered outside of a hospital and 33% in a hospital. In Fulton County there is one CNM delivering 50% of the babies in the county. In many inner city hospitals CNM's deliver 25-30% of the babies (Pennsylvania Hospital, Hahneman Hospital). These statistics do not include the work of nurse-midwives attending births that were transferred for physician care (C-section, forceps, vacuum) or the annual GYN care provided as routine and preventative (breast and GYN cancer screening) health visits for a high percentage of women. C-section and low birth rates are lower for women that have been cared for by nurse-midwives. Education Nurse-midwives are registered nurses with advanced education in Midwifery. Most CNM's have a master's degree (80%) and approximately 4% have doctorates. There are 2 Nurse-Midwifery educational programs in Pennsylvania. The University of Pennsylvania Graduate Program in Nurse Midwifery is a 16 month Masters Degree program. The Institute of Midwifery at the Philadelphia University is a distance learning program that confers a certificate in midwifery at the completion of the program and has Masters Degree completion option. Practice and Reimbursement Issues Nurse-midwifery practice in Pennsylvania is regulated by the Board of Medicine. Nurse-midwives are mandatory MCare h d participants and have received the Mcare abatement from 2003 to CNM's in Pennsylvania receive mandated third party and Medicaid reimbursement. Pennsylvania is the only state in the U.S. where CNM's do not have prescriptive authority. CNM's in Pennsylvania do not have admitting privileges in hospitals.
9 JOINT STATEMENT OF PRACTICE RELATIONS BETWEEN OBSTETRICIAN- GYNECOLOGISTS AND CERTIFIED NURSEMIDWIVESICERTIFIED MIDWIVES The American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse- Midwives (ACNM) recognize that in those circumstances in which obstetrician-gynecologists and certified nurse-midwivedcertified midwives collaborate in the care of women, the quality of those practices is enhanced by a working relationship characterized by mutual respect and trust as well as professional responsibility and accountability. When obstetrician-gynecologists and certified nursemidwivedcertified midwives collaborate, they should concur on a clear mechanism for consultation, collaboration and referral based on the individual needs of each patient. Recognizing the high level of responsibility that obstetrician-gynecologists and certified nursemidwivedcertified midwives assume when providing care to women, ACOG and ACNM affirm their commitment to promote appropriate standards for education and certification of their respective members, to support appropriate practice guidelines, qnd to facilitate communication and collegial relationships between obstetrician-gyaecologists and certified nurse-midwivedcertified midwives. * Certified nurse-midwives are registered nurses who have graduated from a midwifery education program accredited by the ACNM Division of Accreditation and have passed a national certification examination administered by the American Midwifery CertiF~cation Board, Inc. (AMCB), formerly the American College of Nurse-Midwives Certification Council, Inc. (ACC). * Certified midwives are graduates of an ACNM Division of Accreditation accredited, university affdiated midwifery education propm, have successfully completed the same science requirements and AMBC national certification examination as certified nurse-midwives and adhere to the same professional standards as certified nursemidwives. Approved October 1,2002 American College of Nurse-Midwives American College of Obstetricians and Gynecologists 8403 Colesville Road, Suite 1550, Silver Spring, MD fax:
10 of NURSE-MIDWIVES Wllh women, lor a llfetlme* CREATING A CULTURE OF SAFETY IN MlDWIFERY CARE Midwives play an important role in applying principles of patient safety in the care they provide to decrease errors in the health care system. The Institute of Medicine (IOM) and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) have noted common errors in health care that place patients at risk for adverse events at the hands of health care workers. Adverse outcomes in perinatal health care result in significant emotional and financial costs for all. The American College of Nurse-Midwives (ACNM) endorses the following principles to promote patient safety and decrease the risk of adverse outcomes to mothers and babies in labor and birth. Principle #l: Care should be based on scientific knowledge about best practice. ACNM strongly supports the use of evidence-based practice, professional standards and guidelines, and the identification of best practices in the design of care processes as the foundation of care. Evidence-based practice is the integration of best research evidence with clinical expertise and patient values. Syntheses of the evidence base and the development of practice guidelines should contribute to more valid and meaningful quality measures. Principle #2: Interdisciplinary team communication 19 a fundamental aspect of patient care. Communication e m currently account for the majority of preventable adverse outcomes in perinatal care. ACNM encourages all midwives to strive to promote the development and implementation of strategies that foster open, effective, and ongoing communication between all team members. This includes the use of standard abbreviations and nomenclature. A formal mechanism should be established for transfer of care between providers. Principle #3: Active involvement of patients and their fdes in care contributes to safe practice. ACNM recognizes and values the importance of including patients and their families as informed and active team participants in the care process, and considers this an imperative to the promotion of safe outcomes. Principle #4: Participation in quality management programs increases safety, ACNM encourages midwives to participate in quality management programs to effectively evaluate and continuously improve ongoing clinical practice. Strategies that improve the quality of care include, but are not limited to, measurement of outcomes and process, analysis of sentinel events, and use of root cause analysis.
11 ACNM POSITION STATEMENT Creating a Culture of Safety in Midwifery Care ACNM recognizes that clinical practices and models of care may vary according to patient needs and values, and that healthcare can be safely and effectively delivered through a variety of practice models. The safety principles acknowledged in this statement transcend such variances in practice and set forth common principles for midwives to follow in an ongoing commitment to safe and effective care. ACNM recommends that all midwives incorporate these safety principles into their practices in an effort to reduce error and optimize healthy outcomes for the families they serve. Furthermore, midwives are expected to keep abreast of developments in the field of quality improvement research and policy in order to continuously evaluate and improve the quality of care they provide. American College of Obstetrics and Gynecology Committee Opinion #286. Patient safety in obstetrics and gynecology. Obstet Gynecol, 102(4), 883-5: October Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21" Century. Washington DC: National Academy Press; 2004 Joint Commission of the Accteditation of Healthcare Organizations. Preventing Infant Death and Injury during Delivery. Oakbrook Terrace, IL. Sentinel Event Alert #30; Knox GE, Simpson KR. Teamwork: the fundamental building block of high-reliability organizations and patient safety. In Youngberg BJ, Hatlie MJ, eds. The Patient Safety Handbook. Sudbury, MA: Jones and Bartlett; 2004 Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human. Washington DC: National Academy Press; 2000 Source: ACNM DOSP Approved: ACNM Board of Directors, September 2006
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