Recent court cases have also involved propofol. A suit in one case alleges that a patient with sleep apnea died during routine colonoscopy when the CRNA was unable to intubate the patient when he deteriorated after a reduced dose of propofol was administered. In another court case a jury found that the makers of propofol products failed to adequately warn not to reuse 50 ml vials of propofol on multiple patients.
Use of such vials was found in an outbreak of hepatitis C linked to 2 Las Vegas endoscopy centers. Apparently such use of vials for multiple patients has occurred because of the nationwide shortage of propofol. The FDA has been cautioning against such usage and addresses a variety of issues related to the propofol shortage on its website. And propofol is one of those drugs that often goes unlabeled in syringes in ORs or other sites because staff think it is the only cloudy or milky drug likely to be in the field. So there remain many unanswered questions about the safety of propofol for procedural sedation and the best ways to minimize risk of adverse events if it is used.
Until we have more complete answers we recommend:. Note that todays article does not address use of propofol sedation in the intubated, mechanically ventilated patient in the ICU setting. Every attempt should be made to assess the continued need for such sedation. Daily sedation vacations are a key component of the IHI VAP Bundle and other bundles designed to prevent ventilator-associated pneumonia.
Minimizing sedation also helps reduce the incidence of delirium in the intubated, mechanically-ventilated patient. But the article by Strem found that patients who received no sedation had significantly fewer days on ventilators, shorter ICU stays, and shorter total hospital LOS. There was no difference in accidental extubations or VAP, though more patients in the no sedation group had agitated delirium. Those results are actually quite encouraging and the practice of eliminating sedation all together may become more widely accepted if these results can be replicated in other settings.
Propofol can be a very useful drug in a variety of settings. But it may have a small margin for error and there are safety issues lurking whenever it is used. Treat it with respect. Pediatric Academic Societies meeting May 1, HealthLeaders Media, April 13, Emergency Physicians Monthly March 24, Ann Emerg Med ; 51 4: Procedural Sedation and Analgesia. Procedural Sedation and Analgesia in the Emergency Department. American College of Emergency Physicians. May 5, http: Clin Pediatr Phila ; Of Mountains and Molehills. A Randomized, Controlled Trial.
Annals of Emergency Medicine ; 55 3: Green SM, Pershad J. A protocol of no sedation for critically ill patients receiving mechanical ventilation: The Lancet ; A surgeon gets a newly autoclaved instrument that is too hot to use. He sets it down on the surgical drapes. Yes, you know the answers they all resulted in iatrogenic burns to patients. Could they occur in your hospital? We bet they could. Thats because with few exceptions, such as MRI suites and neonatal units, most patient care units lack protocols and systematic assessments to determine who might be at risk for burns.
When you look at the examples above examples you realize there are really 3 key conditions that predispose patients to burns. There may be some additional predisposing factors, too, like impaired ability for the vasculature to help dissipate heat from the skin. And, of course, you need a heat source.
Patients who are obtunded or comatose or who are under anesthesia may not perceive heat or pain or be able to respond even if they could feel it. Patients who cannot communicate infants, patients with aphasia, patients isolated in MRI suites, etc. The patient with the diabetic foot ulcer who suffered a burn due to a warm compress was obviously predisposed by a diabetic peripheral neuropathy a key factor in development of diabetic foot ulcers. But even patients with normal sensation may get burns under certain circumstances. Has the following ever occurred to you? You test the water temperature before you step into the shower and it feels too hot.
You turn the hot water knob down or turn the cold water knob up and the water temperature is comfortable enough for you to begin showering. After a few minutes you increase the water temperature. The increased warmth may, in fact, feel good. But when you finish your shower you notice your skin is much redder than you usually experience.
This was adaptation to heat adaptation probably occurs at both the peripheral receptor level and a central level. You were no longer bothered by water at the same temperature that frightened you at the start. Yet that hot water was capable of burning your skin. The same sort of adaptation takes place to cold ever dive in a 65 degree lake? You shout out Its freezing but after about a minute it becomes more tolerable. So the point is this: The potential damage to skin or other organs is a function of both temperature and duration.
The burn in the patient with the warm compress is interesting from another perspective. One of the first questions we always ask in a root cause analysis RCA after any adverse event is was the procedure indicated in the first place?. They point out that, though there is some basic science research suggesting that heat should improve wound healing, there is really a dearth of clinical evidence that heat therapy is efficacious for wounds. They also point out that wet heat scalding is more likely to cause a burn that dry heat. Microwaved objects are particularly dangerous.
Heating with microwaves is not uniform ever sample safely the periphery of some food only to burn your tongue when you taste the middle?! In addition, some of the warmth remedies for microwaving contain gels, or beans, or rice that retain heat for longer periods than the surface material.
Burns in the OR may occur when heat is applied over an area where drapes over or under the patients skin had been soaked with alcohol or any one of a number of other solutions used in the OR this is also obviously a risk factor for surgical fires see our December 7, Patient Safety Tip of the Week on Surgical Fires ,. In fact, some may develop chemical burns from these liquids. Anesthesia , whether local or regional or general, may predispose patients to burns. Even under general anesthesia, where a patient cannot respond, we wonder if there are subtle signs such as changes in heart rate, perhaps mediated reflexly at lower levels, that could alert the surgical team to a potential burn.
There are special considerations in the neonatal period Mhrenschlager and Mhrenschlager The neonate has a reduced thickness of the stratum corneum, thus less protection against thermal injuries. Thermal injuries in neonates have resulted from exposure to 1 transilluminating devides 2 infrared lamps placed too closely 3 other lights 4 tap water 5 warming bottles 6 even overheated plastic surfaces of disposable diapers. Burns may be an issue during MRI scanning. They stress that even with electrodes that have been approved for use with MRI, a serious burn can develop if the electrodes arent in complete contact with the skin surface for example, if excess hair hasnt been removed or if there is an air gap between the electrode and the skin.
Cables that are looped or coiled are especially likely to overheat during MRI so every attempt should be made to avoid looping or coiling and they should be kept off the patients skin by placing a blanket under them. Our focus in this weeks Tip of the Week is primarily on burns to the skin. However, dont lose sight of the fact that thermal injuries can also occur internally during surgery. Such are well known to structures such as bowel and ureters. Such injuries are often not recognized and result in tissue necrosis and delayed manifestations of symptoms.
Lastly, burns may result from inadvertent radiation overdoses. Iatrogenic thermal injuries in the neonatal period BMJ ; bmj. Report of Two Cases and Review of the Literature. Journal of Burn Care and Research ; Surgical Safety Checklist for Cataract Surgery. Cataract surgery has a special place in our patient safety journey. Our initial interest in surgical timeouts and checklists stemmed from a root cause analysis on an ophthalmology incident. One hand after another shot up! Probably a third of attendees had experienced this at their hospital. Implantation of the wrong intraocular lens was the most common occurrence in both databases.
Errors in both the preoperative period and operative period were found to lead to the incorrect implantation. In the preoperative period, contributory causes identified included faulty calibration of the A-scan equipment, transposition of records from the ophthalmologists office, transcription errors, switched patient identification stickers, and transposition of IOL power calculations while faxing records on two patients at the same time.
Intraoperative errors in almost all cases involved failure to identify the lens specifications properly before implantation. Multiple contributory factors were indentified, including changes in the OR schedule, changed staff assignments, staff changes during the procedure, poor lighting, multitasking and other distractions, and misreading the label on the implant box.
In one case the surgeon had dropped multiple patient charts and they were out of order when reassembled. Note in our June 5, Patient Safety Tip of the Week Patient Safety in Ambulatoy Surgery we discourage the practice of allowing the medical records of multiple patients to be in the operating room since it is too easy to mistakenly pick up the chart of the wrong patient during a procedure. The new Surgical Safety Checklist: The sign in phase done before any anesthetic is administered includes identification of the patient and the procedure to be performed and the consent for that procedure.
It also includes whether site marking has been performed and a precheck of any anesthesiology equipment and whether VTE prophylaxis is indicated. It includes some questions important for anesthesiology allergies, airway accessibility, special needs for draping or positioning. It then asks some questions important to the ophthalmologist: Is the Patient on warfarin? Is the patient on tamsulosin or other alpha blocker? The first question obviously raises the question of bleeding risk and the latter the risk of the intraoperative floppy iris syndrome IFIS and other complications Bell et al During the timeout phase, the team introduces itself and confirms the patient identification, the procedure to be performed, the correct eye, the intended refractive outcome, the power and model of the lens to be implanted, and whether that lens implant is physically present.
Then any anticipated variations or critical events are discussed. For instance, the surgeon may discuss and planned variations in the surgery, need for special equipment, alternative lenses, etc. The anesthesiologist notes the ASA class, status of monitoring equipment, and any patient-specific problems. The scrub nurse notes whether sterility of the instruments has been confirmed and notes any other equipment issues. The sign out phase included documentation of the name and side of the procedure, status and count of all instruments, swabs and other materials, identification of any equipment issues, and instructions for post-procedural care of the patient.
One factor is that a surgeon in ambulatory surgery will often be performing many cases of the same or similar procedures. Interestingly, very experienced surgeons may be more likely to be involved in wrong-site cases, perhaps because their experience allows them to schedule so many cases in one day. The quality of the medical records is often not as good in ambulatory settings.
Often critical information is in the physician office record and never appears in the facility medical record. It is therefore incumbent upon the facility and entire team to ensure the adequacy of the medical record and all documentation prior to the procedure. And there are certain production pressures unique to the ambulatory setting. When a surgeon is booked for many cases in one day, there is a higher likelihood of last-minute changes in the schedule.
Also, weve seen cases in the ambulatory setting where one patient may demand a procedure earlier in the day, leading to last-minute alterations in the order on the schedule. And the pressure to get cases done promptly and stay on schedule are everpresent. Lastly, dont allow the medical records of multiple patients to be in the operating room at the same time since it is too easy to mistakenly pick up the chart of the wrong patient during a procedure.
The recommendations of the American Academy of Ophthalmology Wrong-Site Task Force are also quite valuable and include special attention to intraocular lens implants and a checklist to help. One good recommendation there is that the circulating nurse writes on the white board the patients name, operative eye, IOL style, and IOL power.
WHO Safe Surgery Saves Lives website includes also an implementation manual and videos on how to use the checklist and how not to use it. American Academy of Ophthalmology. Dysphagia in the Stroke Patient: Our June 26, Patient Safety Tip of the Week Pneumonia in the Stroke Patient focused on the evaluation of stroke patients for dysphagia prior to feeding them.
HOME CARE TECHNOLOGY: THE ROWAN REPORT
Much of the morbidity and mortality in patients with acute stroke is related not just directly to the neurological deficit but rather to the complications such as pneumonia. The incidence of pneumonia in the acute stroke population varies considerably in the literature, largely because of stroke populations of varying severity and differences in definitions used.
The human and financial impact of pneumonia in the acute stroke patient are substantial. Use of a formal dysphagia screening tool has been shown to reduce the risk of pneumonia in stroke patients by as much as half Hinchey and there are reports showing that hospitals can increase their compliance with swallowing assessment by using preprinted order sets and by using written care protocols Hinchey , Book We were very disappointed when NQF waffled in on including swallowing assessment in stroke patients as one of its quality measures NQF presumably was concerned because the evidence base was not robust enough.
There has not been a significant change in the evidence base for assessment and management of dysphagia in the stroke patient since then. However, this month the Scottish Intercollegiate Guidelines Network released its guideline Management of patients with stroke: A national clinical guideline. This is the most comprehensive such guideline weve seen. It reviews the evidence base and makes recommendations not only for the assessment of dysphagia in the stroke patient but provides great recommendations about interventions in the dysphagic patient, nutritional status of the stroke patient, issues related to tube feedings, medication issues in the dysphagic patient, oral hygiene in the stroke patient, and training of both professional staff and lay caregivers in important issues.
It also provides good advice about implementing and auditing the guideline and has a variety of useful tools in its appendix section. There is also a good quick reference guide with appropriate algorithms. Hence, assessing patients for dysphagia and aspiration risk is crucial. Note that seeing a patient cough on attempted swallowing is a good indicator of aspiration but the lack of coughing does not indicate safe swallowing.
Factors associated with risk of aspiration are a wet, hoarse voice, a weak voluntary cough, any indication of reduced laryngeal function, and impaired level of consciousness. Factors that have not proven to be accurate predictors of aspiration are pharyngeal sensation and status of the gag reflex. The gag reflex is commonly reduced in the acute phase after stroke. However, some patients with bilateral lesions develop pseudobulbar palsy and may have a normal or even increased gag reflex when their swallowing is impaired. The water swallow test is typically used as a first line tool to screen for aspiration risk.
This screening test is administered by a healthcare professional trained in the procedure, usually a nurse. The Quick Referral Guide and Annex 2 of the full Scottish guideline provide an algorithm for the swallowing screen.
Electronic Health Records (EHRs)
If the patient can sit up and is alert and cooperative and has a clean mouth or has received oral hygiene , the water swallow test can proceed. The patient is sat up and given a teaspoon of water times three. With each teaspoon, the observer watches for absent swallow, cough, delayed cough, and altered voice quality. If the patient passes that initial screen, the patient is observed drinking a full glass of water, again looking for those same abnormalities. If none are witnessed, the patient may start feeding soft options cautiously and observation for coughing or evidence of chest infection are continued.
If the patient fails the initial swallowing screen, a formal assessment should be done by an individual appropriately trained in swallowing assessment, such as a speech therapist. A clinical bedside assessment CBA of swallowing can be done using a standardized tool such as the item Logemann assessment Annex 3 in the full Scottish guideline. The decision of which of these to perform is usually dependent upon individual circumstances eg.
Both tests allow for determination of penetration and aspiration. MBS may be better at determining the reason for dysphagia and aspiration and allow experimentation with various postures, maneuvers and food consistencies to see what might improve the effectiveness and safety of swallowing for each patient.
Diet modification, compensatory techniques, texture modification, and approaches such as muscle strengthening exercises, electrical stimulation and biofeedback are discussed in detail in the guideline. The initial assessment should include not only screening for dysphagia but also screening for risk of malnutrition and risk of dehydration.
Because malnutrition and dehydration may impact on ultimate patient outcomes, they should be addressed by the multidisciplinary team and include a dietitian. For those patients who are unable to safely swallow and are at risk of malnutrition, tube feedings will need to be considered. The guideline has an excellent discussion of the pros and cons of nasogastric tubes and percutaneous gastrostomies PEGs and the timing for conversion from NG to PEG if needed.
They also have a nice section on ethical and quality of life issues and feeding. And a short section on the need for pharmacists to be involved in looking at alternative formulations for necessary medications in those being tube fed. Some of the most important sections deal with those things we tend to often overlook. One is one on the need for regular review of the patients status. Dysphagia in stroke patients often resolves within the first few weeks. Hence, there is a continuing need to reassess the patients swallowing ability and other risk factors for pneumonia and malnutrition.
The guideline stresses that one professional should be identified who will be responsible for this ongoing assessment and reassessment, especially for any patient being tube fed or fed a modified diet. The second has to do with auditing. As you begin implementing the guideline you need to audit current practice to determine where your gaps in care and areas for improvement are.
They provide a nice checklist to help you with that audit. But dont forget that audit and feedback are critical parts in the durability and sustainability of any quality improvement or patient safety activity. The guideline also contains good advice on issues of communication, training of staff, and provision of information for staff, patients and their caregivers.
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Again, this is another good example of how good patient safety programs can be very cost-effective for most hospitals. Pneumonia and urinary tract infection after acute ischaemic stroke: Eur J Neurology ; The cost of pneumonia after acute stroke. The effect of pneumonia on mortality among patients hospitalized for acute stroke. The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Scottish Intercollegiate Guidelines Network.
Management of patients with stroke: Print Dysphagia in the Stroke Patient: How to Do It. The patient safety movement has adopted that approach and much has been written about the role of disclosure and apology after medical errors. Yet we continue to see hospitals struggle with how do we do it? Fortunately, there is a wealth of resources available to help healthcare organizations learn how to do it. Responding to Adverse Events. Why do we recommend disclosure and apology?
It is a moral imperative and it is the only way to maintain the physician-patient relationship and keep the patient at the center of the healthcare system. The fear that disclosure increases the risk of malpractice suits and settlements also was probably erroneous and it is becoming increasingly clear that failure to disclose is a much bigger risk when it comes to malpractice risk. When to invoke the disclosure and apology process is usually a matter of common sense but most guidelines recommend each organization have its own policy that includes a threshold for disclosure.
Most of the serious adverse events requiring disclosure are obvious but you may have to decide individually when to disclose things like near misses. Following are some of the key issues you need to address in the disclosure and apology process. The Canadian guideline also has a nice checklist and algorithm to help you remember key things to do at each stage of the disclosure process.
Obviously, you need to know enough about the event or incident to be able to discuss it with them. But sometimes you may not have all the details early on for example, you may not yet have done your root cause analysis. It is okay to tell them that a serious incident did take place and that your investigation will be taking place within a few days and that you will keep them posted regularly on the status of that investigation. Let them know that you are doing this to help ensure that similar events will be prevented in the future.
You need to show honesty, contrition, and empathy in order to build a trusting relationhip with that patient or family. If you wait to disclose that an incident occurred, the patient or family is likely to find out about it in other ways, your credibility will suffer and you will lose the opportunity to develop a rapport with them. Generally this should be the person with direct responsibility for care of that patient, most often the attending physician.
The Harvard guidelines also mentions joint apologies where the person who made a significant error may join with the attending physician at the time of disclosure and apology. If the care team is different after the incident eg. Both the Canadian and Harvard guidelines strongly suggest organizational training programs to prepare physicians for dealing with disclosure. Housestaff should also participate in any such training offered. Obviously, the meeting needs to take place in a quiet, comfortable setting where interruptions will not occur. The patient and family need to have the opportunity to ask questions and not feel intimidated.
The Harvard Guidelines suggest a single patient room as a good setting or a private office for ambulatory communications. As above, you should disclose the facts as they become known. Sometimes early after an error and adverse outcome, the causes and root causes are not yet known. Be careful about speculating about those causes. Rumors can often run rampant after an adverse event and do not help either the injured patient, the family or the healthcare organization. If you tell a patient or family what you think might be the cause and that turns out not to be the case, your credibility may be damaged.
And then follow up on that promise! The Harvard guideline suggests ways like:. The Canadian Guideline specifically excludes the word error, citing our well-known concept that most cases of adverse patient outcomes are due to system issues. Keep in mind that, while we understand the systems nature of errors that give rise to adverse patient outcomes, patients and families and the public dont have the same level of understanding of those complex issues.
They are looking for someone to take individual responsibility. At the time of disclosure and apology, the attending physicians and hospital administration or other leaders need to make it clear to the patient family what will be done to deal with the clinical effects of the adverse event.
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Very important is the manner in which disclosure and apology occur. And never forget that body language may convey much more than verbal language. Some of their findings were quite surprising. Patients and their families often feared further harm, even retribution, if they express their feelings too forcefully. Family members often have a profound sense of guilt, that they didnt watch carefully enough and were not able to prevent their loved one from suffering in an incident.
That is why it is extremely important to do the disclosure in a manner that makes the patient and family feel comfortable speaking up and allowing both adequate time to ask questions and avoiding any semblance of intimidation. Following up is critical and presents an opportunity to develop rapport and trust that may have been impossible at the first meeting. Followup does not end on discharge from the hospital. Communications should continue after discharge or transfer.
All the while, patients should be supported in medical, social and psychological spheres. The Harvard guideline has good sections on such support and an excellent section on financial support for patients harmed in adverse events. You should document when and where the meetings took place, who was there, what was said, the questions and issues raised, responses given, and what arrangements were made for followup who, when, what. There is also a section addressing disclosure involving multiple patients, a topic we have previously discussed see our June 16, Patient Safety Tip of the Week Disclosing Errors That Affect Multiple Patients.
Pennsylvania has a law that requires hospitals to provide to the patient or appropriate family member or other designee a written notification of a serious event involving that patient within 7 days. A recent article Cherry provides some step-by-step practical advice to help hospitals accomplish that. One very wise piece of advice they offer is not to have more hospital representatives at that meeting than the patient and family have.
Also, this meeting is a time to show humililty and let them know that you have human feelings and its very difficult to convey those traits with opposing teams sitting across from each other at a board room table. So keep it small. Their recommendation is that the hospital have the physician responsible for the patients care, the chief medical officer CMO or VPMA , the risk manager, and perhaps the Chief of Service of the involved department.
Our own recommendation is to leave out the risk manager. You may include your head of quality improvement or patient safety director, especially if you feel they likely be serving as the key liaison for future meetings with the patient and family. Another important point is active listening. We have seen far too many such meetings where the hospital staff dominate the conversation.
This is an opportunity for the patient and family to speak, express their concerns, and ask questions. They should feel they are encouraged to ask questions and expect that those questions will be answered honestly. They stress the value of apology, not only in humanizing the staff, but also in de-escalating tensions, creating a more level playing field, and leading to a more trusting relationship.
HOME CARE TECHNOLOGY REPORT: HEADLINES
While the patient is obviously the focus of the disclosure and apology process, the involved caregiver s are also victims in a sense and need support. Sadness, sense of failure, guilt, isolation, and loss of self-esteem may be overwhelming to some caregivers. Organizations need to recognize this and ensure support is available to caregivers involved in such incidents.
We actually include this as an item in our Serious Incident Response Checklist. Such support may include various types of counseling, appropriate temporary adjustment of responsibilities being careful to ensure that such adjustment is not mistaken as punitive or a sign of loss of confidence in the individual , and the general support that is a feature of the culture of safety. Participation in the root cause analysis and development of strategies to prevent future incidents may also have therapeutic value for the caregiver.
The article mentioned above Guilty, Afraid, and Alone Struggling with Medical Error Delbanco provides excellent insight into how those emotions in clinicians may further compound the emotions the patient or family is going through. They note that physicians experience guilt after a medical error but also have fear after an incident fear about their reputation, job, license, career. That fear, often compounded by imprudent advice from attorneys and administrators, may lead to them becoming isolated and being perceived as cold and impersonal by the very patients and families looking for empathy and support.
Even caregivers not directly involved in the incident may experience similar emotions. We often do debriefing sessions after serious incidents even when no errors occurred. Staff generally feel much better after such sessions. Susan Carr recently summarized findings at a forum on support for clinicians involved in adverse events, identifying numerous barriers that lead to underutilization of such support services. You need to recognize that these emotional stages are part of a normal evolution and that anger may later convert a very positive emotion.
Most in the patient safety movement know the story of the unfortunate death of Josie King at Johns Hopkins and how the anger initially shown by her parents later gave way to a profound understanding of the complex issues in patient safety and the emergence of her mother, Sorrel King, as one of the leading patient safety advocates in the world.
More than 30 states now have apology laws where statements made during apology to patients are not to be used in litigation. Most of these laws are too new for us to tell whether they will have a significant positive impact on the frequency of sincere apology. Massachusetts Coalition for the Prevention of Medical Errors.
When Things Go Wrong. A Consensus Statement of the Harvard Hospitals. Delbanco T, Bell SK. Reporting Adverse Events to Patients: Advancing Programs that Support Clinicians. Patient Safety and Quality Healthcare. Print Disclosure and Apology: Are Your Patients At Risk? For some time now we had planned to do a column on Torsade de Pointes and its relationship to a variety of commonly used medications.
We kept putting it off because of a lack of consensus of how to best monitor for it and how to treat when the risk becomes obvious. Torsade de Pointes is a form of ventricular tachycardia, often fatal, in which the QRS complexes become twisted changing in amplitude and morphology but is best known for its occurrence in patients with long QT intervals. Though cases of the long QT interval syndrome LQTS may be congenital, many are acquired and due to a variety of drugs that we prescribe.
Tip of the Week Archive Apr-Jun 2010
The syndrome is more common in females and many have a genetic predisposition. And there are a number of reasons why this syndrome is more likely to both occur and result in death in hospitalized patients. Subscribe for Free Now!
Rowan Consulting Associates, Inc. Reluctant to leave the healthcare sector he had grown to love, Tim partnered with the leading home health consultant of the time and purchased Home Care Automation Report from its founding publisher. Over the next ten years, HCAR became the most authoritative and respected technology news source in home healthcare.
Following the untimely passing of his mentor and business partner in , Tim carried on their mission to gather, deliver and interpret news about home care technology, regulations, marketing, and other critical issues under the name Home Care Technology Report. The Rowan Report" to reflect the changes in the industry and to encompass a broader range of topics. After ten years in adult religious education positions, he moved to the computer and network hardware and software industry in the fledgling personal computer era, eventually landing back in adult education for a technical training firm.
It was there that Tim was introduced to home healthcare through one of his training clients, who lured him aboard as their first CIO. Regional Health Profiles D. State Health Profiles E. County Health Profiles F. City Health Profiles IV. Health Policy Reference Desk A. Health Policy News K. Health Policy Blogs L. Health Policy Glossary M. Health Policy Humor V. House of Representatives v. A Special Bonus Edition. Lessons On Stopping E.