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HSR&D Studies and QUERI Projects sorted by DREs

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Communication and Decision Making
Project No. sort
Title sort
Funding End sort
VHA Clinicians and Bioterror Events: Interactive Web-based Learning
09/30/2007
Capacity to Execute a Health Care Proxy: Guideline Evaluation
01/31/2003
Innovative Strategies for Implementing New CHF Guideline Recommendations
03/31/2003
Effectiveness of the FairCare System for Patients with Advanced Illness
09/30/2004
Randomized Trial of a Telephone Intervention in Heart Failure Patients
03/31/2005
Computerized Guidelines Enhanced by Symptoms and History: Clinical Effects
02/28/2001
A Multi-Site Study of Strategies for Implementing Schizophrenia Guidelines
09/30/2000
A Randomized Trial to Implement the AHCPR Smoking Cessation Guideline
08/31/2001
Determinants of Clinical Guideline Implementation Effectiveness
09/30/2003
Trial of a Tailored Message Program to Implement CHF Guidelines
03/31/2004
Determination of Clinical Implementation Effectiveness
06/30/2001
Knowledge Management and Clinical Practice Guideline Implementation
06/30/2002
Benchmarking Patterns in the Pharmacologic Treatment of Major Depressive Disorder (MDD)
03/31/2002
Guidelines for Drug Therapy of Hypertension: Multi-Site Implementation
09/30/2005
Barriers and Facilitators to PTSD Treatment Seeking
12/31/2007
Further Development and Validation of the DRRI
03/31/2008
Disease Managment and Educational Intervention Outcomes in High-Risk Diabetics
12/31/2002
Impact of a Quality Management Intervention Upon Foot Care Outcomes
07/31/2001
Medicaid Enrollment, Utilization and Outcomes for VA Patients
03/30/2008
VA Enrollees' Demand for VA and non-VA Care
09/30/2003
Determinants of VA Ambulatory Care Use Among Native American Veterans
06/30/2003
Reasons for Disparities in Joint Replacement Utilization
12/31/2006
Racial Variations in Cardiac Procedures: Do Health Beliefs Matter?
09/30/2001
Ethnic Differences - Management of Patients with Ischemic Heart Disease
09/30/2003
Health Seeking and Treatment Selection in Patients with Coronary Disease
07/31/2002
Veterans Women's Alcohol Problems: Prevalence, Screening and Self-Help
09/30/2001
Decision Making for Depression in Women Veterans: Patient and Physician Factors
06/30/2001
Identification of HIV Infection Among Veterans
09/30/2003
Determinants of Adherence to Antiretroviral Therapy and Impact on Outcomes
09/30/2002
A Medication Adherence Intervention for HIV Infected Veterans
12/31/2002
Improving HIV Care Quality
12/31/2004
Reducing Transition Drug Risks after Patient Transfer
10/01/2009
Implementation of Real-Time ADE Surveillance and Decision Support
03/31/2009
Adapting Tools to Implement Stroke Risk Management to Veterans
02/28/2010
A Self-Management Intervention for Veterans with Hepatitis C
08/31/2009
Senior Coordinated Referral (SCORE) Study
06/30/2010
Benefits of 'Repeat Back' Protocols within A Computer-Based Informed Consent Program
03/31/2009
Operating Room Workload and Quality of Care
06/30/2010
Effects of Outlier Identification Strategy on Facility Profiling
09/30/2005
Improving Antipsychotic Adherence Among Patients with Schizophrenia
06/30/2006
Clinical Reminders in Test Reports to Improve Guideline Compliance
09/30/2006
Process of Care in Peripheral Arterial Disease
09/30/2005
Improving Care of Veterans by Using Consumers as Mental Health Providers
06/30/2007
The Impact of Health Literacy on Racial Differences in Cancer Stage at Presentation
03/31/2007
Variation in ICU Outcome: Examination of Contributing Factors
09/30/2004
Addressing Barriers to Translation for Treatment of Hypertension
02/28/2008
Assessing Practice Variation in Long Term Care Referrals
09/30/2006
Measuring Quality of Family Experience of Patients with Serious Illness
12/31/2008
Improving the Quality of End-of-Life Communication for Patients with COPD
12/31/2007
Intervention to Improve Care at Life's End in VA Medical Centers
06/30/2010
Patient Preferences for Treatment of Hepatitis C
09/30/2008
Improving Patient-Provider Communication For Colorectal Cancer Screening
12/31/2009
Diabetes Telemedicine Consultation: A Systems Improvement Intervention
03/31/2009
Surveillance of Medical Device-Related Problems in Intensive Care Units
04/30/2009
Improving HIV Screening by Nurse Rapid Testing, Streamlined Counseling
06/30/2007
Identifying and Predicting Contextual Errors in Medical Decision Making
08/30/2009
Joint Replacement Utilization Disparity: The Role of Communication
02/28/2009
Insulin Treatment Variation in Southwestern Diabetics - Therapeutic Decision-making
04/30/2008
Patient and Provider Attitudes in the Healthcare Context
06/30/2010
Stroke Prevention in Atrial Fibrillation: Impact of Mental Illness
03/31/2009
PSA Failure: A Rising Concern for Prostate Cancer
05/31/2009
Behavioral/Pharmacological Telemedicine Interventions for BP Control
09/30/2009
Culture and Communication in Hypertension Management
09/30/2009
Caregiver Psychoeducation and Support: Improving Outcomes in AD/ADRD
03/31/2011
Family-Supported Smoking Cessation for Chronically Ill Veterans
06/30/2012
Sociocultural Dimensions of Provider Decision-Making in Pain Management
08/31/2009
Team Process and Performance in Primary Care
12/31/2009
Intra-Operative Predictors of Adverse Outcomes
12/30/2009
Knee Replacement Disparity: A Randomized, Controlled Intervention
08/31/2009
Barriers to Initiating Antiviral Therapy for Veterans with Hepatitis C
08/31/2010
Impact of a Plain Language Prostate Cancer Decision Aid on Decision Making
09/30/2011
Surgical Case Duration in the Department of Veterans Affairs
03/31/2009
The Influence of Obesity on Veterans' Quality of Care
09/30/2010
Evaluating a Preference-based Intervention for Increasing CRC Screening
03/31/2012
Enhancing caregiver support for patients with heart failure
06/30/2012
Pain, Sexual Dysfunction and Depression in Hemodialysis Patients
07/31/2011
Patient Preferences and the Care of Diabetes
02/28/2001
Perceptions of the C&P Process for PTSD: Symptoms and Service Utilization
01/31/2004
Mental Health Providers' Perceptions of Quality Indicators
02/28/2001
Cost Effectiveness of Guidelines-Concordant Care for Schizophrenia
06/30/2001
Variation in VA Dental Procedures
09/30/2003
Measuring the Quality of Dying
09/30/2002
Application of Clinical Decision Aids for Acute Upper GI Hemorrhage
03/31/2003
Facilitating Shared Decisionmaking About Prostate Cancer Screening
12/31/2002
Collaboration between VA and Academic Experts in Implementation Research
09/30/2006
A Hip Protector Program to Increase Use in Primary Care Patients
06/30/2004
Strengthening Organization to Implement Evidence-based Clinical Practice
06/30/2008
VISN Collaborative for Improving Hypertension Management with ATHENA-HTN
09/30/2009
Implementation/Evaluation Evidence-based Coordinators in Residency Training
06/30/2004
Virtual Innovation Partners: Dissemination of PTSD Evidence-based Practices
05/31/2005
Innovations to Implementing Evidence-based Clincial Practice
09/30/2004
Training in Cognitive Processing Therapy for Sexual Trauma-related PTSD
04/30/2005
Implementing Telemedicine-Based Collaborative Care for MDD in Contract CBOCs
03/31/2009
Racial/Ethnic Differences in Trust/Mistrust and its Effect on Diabetes Outcomes
09/30/2008
Improving Outcomes of Depression in Primary Care
12/31/2004
Online Family Education to Promote Treatment Compliance in Schizophrenia
09/30/2004
Well-being Among Veterans Enhancement Study (WAVES)
09/30/2005
Mental Health QUERI Translation Plan to Improve Antipsychotic Treatment
03/31/2004
Cost & Value of Evidence Based Solutions for Depression (COVES)
12/30/2006
Negotiating Patient Expectations and Requests in a Managed Care Environment
03/31/2001
Evaluation of VA Practice Matters as a Strategy for Influencing Physician Behavior
03/31/2003
Palliative Care Transitions: Factors in Patient Experience and Satisfaction
12/31/2006
Early Trajectory of Wandering in Veterans with Mild Dementia
03/31/2012
Minimizing Harm from ADEs by Improving Nurse-Physician Communication
04/30/2009
Using Pain Resource Nurses to Improve Cancer Patient Pain Outcomes
12/30/2000
Adherence to Antiretroviral Therapy in HIV Infected Adults
12/30/2000
Improving Cancer Pain Management Using AHCPR Cancer Pain Guidelines
09/30/2004
Documenting Barriers to Patient-Centered Care in an Academic Clinic
03/31/2002
Can Interactive Voice Response Improve Patient-Centered Outcomes for Veterans
06/30/2004
The Patient Centered Treatment of Dually Diagnosed Veterans
12/31/2002
Development and Evaluation of a Hormone Replacement Therapy Decision-Aid
03/31/2004
Patient-Centered Alternative to Psychiatric Hospitalization for Veterans
09/30/2002
Communication, Alternatives, and Preferences in End of Life Care
08/31/2002
An Illustrated Patient Satisfaction Evaluation Tool for Ambulatory Populations
09/30/2002
Low Literacy Intervention for Colorectal Cancer Screening
04/30/2003
Treatment Decision Intervention for Veterans with Prostate Cancer
12/31/2001
Assessing the Needs of VA Patients with Advanced Cancer
09/30/2001
Improved Clinical Decision Making for Stroke Prevention
09/30/2007
CPRS Diabetes Food Reminder-Based Registry and Decision Support Tool
09/30/2007
Long-Term Care Referral Tutorial
12/31/2007
Psychometric Validation of an Organizational Readiness-to-Change Scale
03/31/2008
Improving Patient-Provider Communication about Routine HIV Screening
03/31/2008
Translating Infection Prevention Evidence to Enhance Patient Safety
09/30/2008
Randomized Controlled Trial of Enhanced Pharmacy Care in Older Veteran Outpatients
03/31/2004
Veterans' Views of HIPPA, Privacy Protection and Health Services Research
12/31/2004
Validating the Patient Safety Indicators in the VA: A Multi-faceted Approach
09/30/2011
Understanding Variations in the IRB Review Process: Pilot Study
09/30/2008
System for Monitoring Substance Abuse Patients' Outcomes and Care
06/30/2005
Clinical Practices and Outcomes in VA Methadone Maintenance Programs
06/30/2004
Internet-based Diabetes Education and Case Management
12/31/2008
Effect of Telemedicine on Physician-Patient Communication
10/30/2007
Factors Influencing Success of Computerized Clinical Reminders in VA
12/30/2005
From Research to Practice - Lipid Management for Low HDL-Cholesterol
09/30/2003
Use of CPRS Templates to Standardize Drug Utilization Reviews
06/30/2005
Computer-Assisted Access to Specialist Expertise
12/31/2002
Improving Health Services for Veterans with Schizophrenia
03/31/2003
Implementation of Ischemic Heart Disease Clinical Practice Guidelines
09/30/2002

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Diagnosis and Prognosis
Project No. sort
Title sort
Funding End sort
Pressure Ulcer Assessment via Telemedicine
09/30/2000
Improving Antibiotic Use in Acute Care Setting
06/30/2007
Chronically Ill at the VA: Who Are They and What Do They Need?
06/30/2002
Measurement and Outcomes Post Severe Brain Injury
09/30/2010
Improving Diabetes Care via Telephone Assessment and Patient Education
05/31/2003
Risk of Mortality in Prostate Cancer
06/30/2001
Identification of HIV Infection Among Veterans
09/30/2003
Determinants of Adherence to Antiretroviral Therapy and Impact on Outcomes
09/30/2002
Evaluation of Store-Forward Teledermatology for Skin Neoplasms
06/30/2005
The Impact of Health Literacy on Racial Differences in Cancer Stage at Presentation
03/31/2007
Variation in ICU Outcome: Examination of Contributing Factors
09/30/2004
Impact of Diastolic Heart Failure on Health Care Utilization and Outcomes
06/30/2005
Development of Survival Prediction Models for Advanced Cancer Patients
06/30/2008
Evaluating HIV/AIDS Care Access and Quality in the VA
09/20/2007
Improving Care for Nursing Home Pneumonia in NHCUs and Veterans' Homes
09/30/2005
Cost Effective Strategy to Evaluate Veterans with Sleep Apnea
03/31/2009
Clinical and Cost Effectiveness of Screening for Diabetic Retinopathy Using Tele-Ophthalmology
12/31/2010
Electrodiagnostic Services: Guidelines, Compliance, and Outcome
08/30/2009
Partners in Dementia Care
02/28/2011
Impact of Health Status on Colorectal Cancer Screening in Older Adults
12/31/2010
Quality of Practices for Lung Cancer Diagnosis and Staging
03/31/2010
Dementia in Primary Care: Setting the Stage for Quality Improvement
03/31/2010
Using Knowledge Discovery Strategies to Identify Fall Related Injuries
06/30/2010
Predicting Antibiotic Resistant Bacteria Carriage at Hospital Admission
08/30/2009
Novel Cardiovascular Risk Factors in Renal Insufficiency
03/31/2010
Quality of Care Among Patients with Chronic Hepatitis C Virus Infection
03/31/2011
Pain, Sexual Dysfunction and Depression in Hemodialysis Patients
07/31/2011
A Patient-Centered Approach to Improve Screening for Side Effects of SGAs
06/30/2011
Treating Violence-Prone Substance Use Disorder Patients
08/31/2012
Development of Individual-Patient Physical Health Profiles with IRT
12/31/2000
A Casefinding and Referral System for Older Veterans within Primary Care
09/30/2001
Post Traumatic Stress Disorder Among VA Ambulatory Care Patients
09/30/2000
Validation of Spanish Translation of Folstein Mini Mental State Exam
03/31/2001
Validity of New and Original ASI Summary Indices
03/31/2002
Development and Validation of a Computerized Trauma History/PTSD Screen
09/30/2001
Audiology Visits after Screening for Hearing Loss: An RCT
06/30/2005
Implementing USPSTF/AHCPR Guidelines for Depression in Primary Care
06/30/2004
The Diagnostic Validity of Three Quantitative Swab Techniques
06/30/2004
Sleep and Behavioral Disturbance in Dementia
03/31/2007
Early Trajectory of Wandering in Veterans with Mild Dementia
03/31/2012
Predictors of Outcomes of HIV-Infected Males
09/30/2005
Culturally Sensitive Models of Stroke Recovery and Caregiving After Discharge Home
03/31/2006
Demonstration Project: A Method for Patient-Centered Improvements
03/30/2005
Development of a Cancer Pain Prognostic Scale
12/31/2002
Evaluating the Implementation of Rapid Testing for HIV infection in a VA Emergency Department
09/30/2008
Suicide and Firearm Experience (SAFE): Developing Strategies to Increase Veterans Safety
04/30/2008
Pain Assessment in Polytrauma Rehabilitation Centers
09/30/2008
Development of an Evidenced-Based Acute Care Dysphagia Screen
03/31/2008
Ability to Cough to Predict Dysphagia in Rehabilitation Patients
04/30/2008
Transition from TBI Screen to Full Assessment: Barriers & Facilitators
12/31/2008
Pilot Validation of the VA NAtional Data Repository
09/30/2008
Implementation and Evaluation of a VISN-based Program to Improve HIV Screening and Testing
04/30/2008
Pain, Psychiatric Disorders, and Disability Among Veterans with and without Polytrauma
06/30/2010
Planning/Pilot-Prospective Study of the Psychological, Social, and Biological Markers (Genomic Determinants) of Risk and Resilience for Operational Stress in Marines
09/30/2007
Planning and Development Toward "Comparing Signs and Symptoms of OEF/OIF Veterans with PTSD to Veterans with PTSD/TBI Using Concept-Baed Indexing fo C&P Narrative Reports
06/30/2008
Planning and Development Toward "Biochemical Surveillance of OEF/OIF Deployed Soldiers Using Natural Language Processing Detection of BDD Records"
06/30/2008
Gender and Medical Needs of OIF/OEF Veterans with PTSD
10/30/2007
Qualitative Assessment of Implementing Routine Rapid HIV Testing
12/31/2008
Gender and Medical Needs of OEF/OIF Veterans with PTSDII
09/30/2008
Genetic Testing Decision Analysis Model for Antidepressant Treatment
09/30/2008
Measuring Quality of Colonoscopy in VA Medical Centers
09/30/2008
Assessment of Sight-Threatening Diabetic Retinopathy Status via Telemedicine
04/30/2003
Prevalence and Recognition of PTSD in VA Primary Care
12/31/2002

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Epidemiology
Project No. sort
Title sort
Funding End sort
Chronically Ill at the VA: Who Are They and What Do They Need?
06/30/2002
Blast-Related Health Problem Identification and Polytrauma Taxonomy
12/31/2010
Physical and Sexual Assault in Deployed Women: Risks, Outcomes and Services
06/30/2009
Women Veterans Cohort Study
10/30/2012
Veterans Women's Alcohol Problems: Prevalence, Screening and Self-Help
09/30/2001
Improving the HIV/AIDS Immunology Case Registry
09/30/2002
Data Collection for Veterans with HIV/AIDS: Survey and Chart Review
12/31/2002
Participation in PTSD: Who Starts, Who Stays and Who Drops Out
06/30/2010
Causes and Consequences of Aggressive Behavior in Demented Patients
06/30/2007
Nurse Staffing and Patient Outcomes in VA
09/30/2005
Stroke Prevention, Incidence and Outcomes in Veterans with Diabetes
03/31/2009
Inappropriate Prescribing of Medication for Older Veterans
09/30/2005
Impact of Diastolic Heart Failure on Health Care Utilization and Outcomes
06/30/2005
Appropriateness of Antiepileptic Drug Use for Older Veterans
09/30/2008
Use of VA and Medicare by Older Veterans with New Disability
06/30/2008
Hip Fracture Repair and Outcomes: A National Cohort Study of Veterans
12/31/2008
Amputation Related Trends, Health Care Use, and Outcomes in Veterans
09/30/2008
Quality of Care and Outcomes in Veterans with PreEnd State Renal Disease
03/30/2009
Antibiotic Use, Resistance and Clostridium Difficile-Associated Diarrhea
08/30/2007
Variability in Surgical Blood Transfusion Practices and Cardiovascular Outcome
12/31/2007
The Impact of Neighborhood Environment on Veteran Health and Survival
09/30/2009
Health Care Use, Outcomes, and Costs of Comorbid Diabetes and Depression
08/30/2009
Quality of Practices for Lung Cancer Diagnosis and Staging
03/31/2010
Longitudinal Analysis of Utilization and Cost by VA Patients with Diabetes
12/30/2011
Inappropriate Drug Use for Seniors: Should VA adopt new HEDIS measures
06/30/2010
VA and Non-VA Healthcare Utilization and Outcomes by Veterans with Stroke
09/30/2009
From Syndromic to Disease-Course Surveillance
09/30/2010
Quality of Care Among Patients with Chronic Hepatitis C Virus Infection
03/31/2011
A Smoking, Alcohol, and Depression Intervention for Head and Neck Cancer
03/31/2004
Correlates of Falls in Persons with Cancer
12/31/2004
Detection of Intimate Partner Violence: Implications for Interventions
06/30/2011
Effects of Patient's Models of Heart Disease on Preventative Behaviors
03/31/2011
Nurse Physical Activity Counseling in Primary Care
03/31/2006
Immunocompetency and Nutritive Status in Inpatient Gero-Rehabilitation
09/30/2007
Pilot Validation of the VA NAtional Data Repository
09/30/2008
Race in VA Cooperative Studies Projects
06/01/2002
Enhancing Equitable and Effective PTSD Disability Assessment
01/31/2009
Long-Term Outcomes in Burned OEF/OIF Veterans (LOBO)
09/30/2012
Planning and Development Toward "Comparing Signs and Symptoms of OEF/OIF Veterans with PTSD to Veterans with PTSD/TBI Using Concept-Baed Indexing fo C&P Narrative Reports
06/30/2008
Planning and Development Toward "Biochemical Surveillance of OEF/OIF Deployed Soldiers Using Natural Language Processing Detection of BDD Records"
06/30/2008
Neuropsychological Assessment of a Population-Based Sample of Persian Gulf War Veterans and Controls
06/30/2004

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Etiology
Project No. sort
Title sort
Funding End sort
Periodontal Care and Glycemic Control in Diabetes
09/30/2003
Health Values and Spirituality in Veterans with HIV/AIDS
06/30/2005
Causes and Consequences of Aggressive Behavior in Demented Patients
06/30/2007
Process of Care in Peripheral Arterial Disease
09/30/2005
The Impact of Health Literacy on Racial Differences in Cancer Stage at Presentation
03/31/2007
Variation in ICU Outcome: Examination of Contributing Factors
09/30/2004
Risk Factor Trajectory and Variability: Predictors of Vascular Disease?
06/30/2006
Nurse Physical Activity Counseling in Primary Care
03/31/2006
Immunocompetency and Nutritive Status in Inpatient Gero-Rehabilitation
09/30/2007
Environmental Exposures Assessment Tool (EE-Tool) for OIF/OEF Veterans
09/30/2008

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Pathophysiology
Project No. sort
Title sort
Funding End sort
Sexual Violence and Women Veterans' Gynecologic Health
03/31/2008
Optimizing Rheumatoid Arthritis Disease Modifying Anti-rheumatic Drugs
09/30/2008
Genetic Testing Decision Analysis Model for Antidepressant Treatment
09/30/2008

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Prevention
Project No. sort
Title sort
Funding End sort
Implementing Guidelines for Smoking Cessation: A Randomized Trial of Evidence-Based Quality Improvement
12/31/2002
Veterans Women's Alcohol Problems: Prevalence, Screening and Self-Help
09/30/2001
Reducing Transition Drug Risks after Patient Transfer
10/01/2009
Adapting Tools to Implement Stroke Risk Management to Veterans
02/28/2010
Proactive Tobacco Treatment for Diverse Veteran Smokers
06/30/2012
Working with Veterans Organizations to Improve Blood Pressure
12/31/2010
A Self-Management Intervention for Veterans with Hepatitis C
08/31/2009
Predicting Post-Deployment Mental Health Substance Abuse and Services Needs
09/30/2009
Participation in PTSD: Who Starts, Who Stays and Who Drops Out
06/30/2010
Evaluation of Military Sexual Trauma Screening and Treatment
01/31/2009
Clinical Reminders in Test Reports to Improve Guideline Compliance
09/30/2006
Preventing Pressure Ulcers in Veterans with Spinal Cord Injury (SCI)
09/30/2005
Process of Care in Peripheral Arterial Disease
09/30/2005
Evaluation of Preventable Diabetes Hospitalizations in the VA
06/30/2007
Prospective Study of Functional Status in Veterans at Risk for Unexplained Illnesses
12/31/2009
Epidemiology and Cost of Falls in Veterans with Spinal Cord Injury
08/31/2008
Can Group Visits Improve Outcomes of Veterans with Diabetes
01/31/2009
VA Prescription Drug Company Copayments and Veterans with Diabetes or Hypertension
09/14/2006
Improving Patient-Provider Communication For Colorectal Cancer Screening
12/31/2009
Recurrence after Treatments of Nonmelanoma Skin Cancer
06/30/2009
Manifestations, Causes, and Consequences of PEU in Elderly TCU Residents
04/30/2011
MST Effects on PTSD and Health Behavior: A Longitudinal Study of Marines
08/30/2009
Quality of Practices for Lung Cancer Diagnosis and Staging
03/31/2010
Obesity Care Practices in the Veterans Health Administration
06/30/2009
Predicting Antibiotic Resistant Bacteria Carriage at Hospital Admission
08/30/2009
Family-Supported Smoking Cessation for Chronically Ill Veterans
06/30/2012
Sleep Specialty Consultation: Improving Management or Sleep Disorders
12/31/2010
A Patient-Spouse Intervention for Self-Managing High Cholesterol
08/30/2009
NSAID Related Adverse Events: Evaluating Risk Using Clinical Information
06/30/2008
Depression and CHF in Outpatients
02/28/2010
Evaluating a Preference-based Intervention for Increasing CRC Screening
03/31/2012
Enhancing fitness in older overweight vets with impaired fasting glucose
06/30/2011
Enhancing Indoor, Community, and Advanced Wheelchair Skills in SCI
12/30/2010
A Patient-Centered Approach to Improve Screening for Side Effects of SGAs
06/30/2011
Study to Lower Veterans Blood Pressure: Patient/Physician Intervention
03/31/2006
Dermal Thermometry and Self-Care of High Risk Diabetic Patients
09/30/2006
Unexpected Clinical Events: Impact on Patient Safety
06/30/2004