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Acadia addiction treatment addition adverse events alpha sites Ascension Health assessment best practices birth trauma clients clinical collaborative communication components concems conscious sedation Dana-Farber Cancer Institute deans deﬁned deﬁnition developed difﬁcult ensure Error Prevention factors faculty ﬁeld ﬁndings ﬁrst ﬁve Healthcare hospital ical identiﬁed implementation incidence included infusion initiatives Institute intralipid involved issues Journal on Quality Jt Comm last accessed Oct leadership learning Medical Center medical errors Medical School Medication Safety Medicine ment MEPI midazolam Neonatal NIATx nurse Ofﬁce organizational organizations OSCE OSCE station outpatient participants patient identiﬁcation patient misidentiﬁcation Patient Safety patient safety liaisons PDSA pediatric Ph.D physicians potential providers Quality and Patient quality and safety quality improvement reﬂected reported Research response SBAR service quality Seton Seton Medical Center signiﬁcant speciﬁc staff strategies structured tion University unsafe Yes Nurse Yes Service Yes