Content uploaded by Rocío Juliá-Sanchis
Author content
All content in this area was uploaded by Rocío Juliá-Sanchis on Oct 31, 2018
Content may be subject to copyright.
Handover of Patients From
Prehospital Emergency
Services to Emergency
Departments
A Qualitative Analysis Based on Experiences of Nurses
Ángela Sanjuan-Quiles, PhD, RN; María del Pilar Hernández-Ramón, MSc;
Rocío Juliá-Sanchis, PhD, RN; Noelia García-Aracil, PhD, RN;
MªElena Castejón-de la Encina, PhD, RN; Juana Perpiñá-Galvañ, PhD
ABSTRACT
Background: During the transfer of patients, both ambulance and hospital emergency service professionals
need to exchange necessary, precise, and complete information for an effective handover. Some factors
threaten a quality handover such as excessive caseload, patients with multiple comorbidities, limited past
medical history, and frequent interruptions.
Purpose: To explore the viewpoint of nurses on their experience of patient handovers, describing the essential
aspects of the process and areas for improvement, and establishing standardized elements for an effective
handover.
Methods: A qualitative research method was used.
Results: Nurses identified the need to standardize the patient transfer process by a written record to support
the verbal handover and to transmit patient information adequately, in a timely manner, and in a space free of
interruptions, in order to increase patient safety.
Conclusions: An organized method does not exist. The quality of handovers could be enhanced by improve-
ments in communication and standardizing the process.
Key words: communication, emergency department, handover, nursing, prehospital emergency services
The process of handing over a patient is
dened as the transfer of responsibility,
clinical information, and care of a patient from
Author Affiliations: Health Sciences Faculty, University of Alicante,
Carretera San Vicente del Raspeig, Spain (Drs Sanjuan-Quiles,
Juliá-Sanchis, García-Aracil, Castejón-de la Encina, and
Perpiñá-Galvañ); and Vega Baja Hospital, Orihuela, Alicante, Spain
(Ms Hernández-Ramón).
The authors declare no conflicts of interest.
This is an open-access article distributed under the terms of the
Creative Commons Attribution-Non Commercial-No Derivatives
License 4.0 (CCBY-NC-ND), where it is permissible to download and
share the work provided it is properly cited. The work cannot be
changed in any way or used commercially without permission from
the journal.
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML
and PDF versions of this article on the journal’s Website
(www.jncqjournal.com).
Correspondence: Rocío Juliá-Sanchis, PhD, RN, Health Sciences
Faculty, University of Alicante, Carretera San Vicente del Raspeig
s/n -03690 San Vicente del Raspeig, Spain (rjulia@ua.es).
Accepted for publication: June 4, 2018
Published ahead of print: July 18, 2018
DOI: 10.1097/NCQ.0000000000000351
one health care professional to another.1,2 This
process involves a series of actions, which guar-
antee the coordination and continuity of care.3
However, handovers are not devoid of risks
due to factors inherent to the organization of
prehospital emergency medical services (PEMS)
and hospital emergency departments (EDs),
which can result in errors in communication
during the transfer of patients between health
care professionals.3These factors include the di-
versity of patient conditions attended to by such
services, more than one health care professional
caring for any given patient, limited information
about the patient’s medical history, excessive
caseload, limited time frames, and continuous
interruptions.4,5
Likewise, PEMS have only one opportunity
to transfer information to the ED, and as such,
whatever data are not transmitted, acquired,
or recorded in the patient’s clinical notes dur-
ing handover are lost.4These circumstances
can lead to discontinuity in care, increased
J Nurs Care Qual • Vol. 0, No. 0, pp. 1–6 • Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. www.jncqjournal.com 1
2Handover of Patients From Prehospital Emergency Services to EDs Journal of Nursing Care Quality
variability in clinical practice, decreased proce-
dural integrity, and the occurrence of adverse
events in up to 60% to 80% of cases.6,7 To
counteract such unfavorable situations in the
organization, standardization and consistency
of the handover process, to enhance the effec-
tiveness of communication during handover, is
needed.8-11
BACKGROUND
A number of authors have performed research
on strategies for improving handover in a range
of contexts, from operating room to pediatric
intensive care units.12,13 All of them found that
using checklists reduces data loss and medical
errors related to failures in communication, im-
proves information content at handover and the
quality and reliability of the information trans-
mitted, and enhances clinical safety.13,14 Klim
et al,15 in a survey and group discussion forum
with ED nurses, identied that the information
received, the past medical history, and vital signs
of the patient were not checked for accuracy
by most health care professionals, resulting in
an inadequate and poor-quality handover.16 It
is worthy of note that studies related to the
transfer of patients between ambulance services
and EDs are limited.10 Due to the fact that the
lack of standardization of handovers increases
the likelihood of adverse events, the purpose
of this study was to explore the viewpoint
of nurses on their experience of patient han-
dovers, describing the essential aspects of the
process, identifying the weak points, and estab-
lishing standardized elements for an effective
handover.
METHODS
A qualitative study design was used within the
theoretical framework of a content analysis.
To systematically organize the resultant data,17
semistructured, face-to-face interviews were
recorded in an audio format, transcribed verba-
tim, and analyzed by 3 independent researchers
who did not participate in the interviews.
All participants were informed of the aim of
the study, the methods used, and how they would
participate. Prior to being interviewed, informed
consent was obtained, and we received autho-
rization from the PEMS management and hos-
pital management team to which the personnel
interviewed belonged.
Sample
The initial study sample consisted of 30 nurs-
ing professionals from the province of Ali-
cante (Spain). Recruitment was performed via
nonprobabilistic intentional sampling, which in-
cluded nurses working in PEMS and EDs who
met the following inclusion criteria: currently
employed and having at least 2 years of expe-
rience in these specialist areas. Finally, 12 nurses
satised the inclusion criteria and participated in
the study. Seven of them were female, and the
mean age was 36.2 years. Their average years
of experience were 11.6, and half of the partici-
pants were from PEMS.
Procedure
Once participants had been selected, one
research team member contacted them via
e-mail. Then, the study was explained, and they
were invited to participate. The interviews were
held from March to April 2017. The particular
areas of interest of the study were included in
the formulation of 10 open-ended questions,
based on the literature review and the specic
aims of the project. Nurses were asked about: (1)
standardization of the process, (2) effectiveness
of the transfer process, (3) essential elements to
handover, (4) organization of information, (5)
prompting the information to be provided or
received, (6) communication techniques, (7) a
proper handover, (8) key information, (9) infor-
mation to continuity of care, and (10) improving
the status quo of the transfer of care.
Data analysis
Researchers ensured the data gathered from
the interviews were coherent and accurate. The
interviews were recorded in a digital audio
format, transcribed verbatim, and subsequently
provided to the participants for the accuracy
of the transcription to be corroborated. The
data were processed using a qualitative content
analysis methodology.18 The interviews were
analyzed via data triangulation, applying an
open codication system, which consisted of
assigning emergent codes to each paragraph
or sentence according to their meaning. These
codes were classied into groups according to
similarity. Subsequent to identifying patterns
in the transcriptions, the classications were
divided into topics and subtopics.
Data saturation was reached once 10 inter-
views had been transcribed and triangulated by
00 2018 • Volume 0 • Number 0 www.jncqjournal.com 3
the research team. Informatics software was not
used in performing the content analysis. Once
potential differences with regard to the available
literature and/or conceptual frameworks were
identied, the content was examined, and con-
sensus reached on the more relevant data re-
lated to each topic and subtopic. The reliability
of qualitative data was achieved via a systematic
process of data gathering and analysis.19
RESULTS
Four topics and 11 subtopics were generated,
as shown in the Supplemental Digital Content,
Table, available at: http://links.lww.com/JNCQ/
A463.
Standardization
Within this topic the subtopics were: protocols,
clinical safety, and patient-family participation.
Standardization is the process by which an activ-
ity is performed in a previously established me-
thodical manner, subject to consensus as the ac-
ceptable procedure for performing certain types
of activities or functions.20
When the nurses were asked whether they con-
sidered it necessary to standardize the transfer
process, all agreed that the standardization of
the process was essential. Furthermore, 6 of them
stated that standardization could avoid data loss,
errors, and mistakes. Consequently, the stan-
dardization of the handover process would im-
prove clinical safety. A nurse stated, “Standard-
izing the process would be of interest to avoid
omissions and errors and for everyone to work
in a more homogenous way.” Also, another said,
“If a protocol existed, we could avoid gaps in
information.”
The transfer process
The following subtopics were included with this
area: patient details, data organization, and hos-
pital organization. Regarding the question of
which information should be included in the
transfer process, all of the nursing profession-
als surveyed highlighted the following areas as
important: the presenting complaint or reason
for referral, personal history, allergies, treatment
or care received, and medications administered.
Six of nurses considered it essential to know
about the previous condition of the patient and
the effectiveness of any treatment administered.
Only one of the participants felt it unnecessary
to be informed about IV line, catheters, or oxy-
gen therapy, stating that visual cues are retained
and thus they did not require such information
to be reported.
The ED nurses highlighted the need to obtain
information about the patient and any nursing
tasks performed prior to their arrival. A nurse
stated:
The handover brought in by PEMS should in-
clude any nursing tasks that have been per-
formed (IV line), the presenting complaint, and
main actions performed, and above all, whether
they have had the time or the opportunity to
speak with the patient and family members…[to
identify] drug allergies and main medical condi-
tions contributing to the patient reaching a crit-
ical state … to know if they found the patient
lying on the oor, if they have seen home oxygen
equipment in the house, any information one can
get is always good to know, especially in emer-
gency cases.
It is noteworthy that each nursing professional
organized information in different ways. They
expanded or dismissed information according
to their clinical judgment and mental schemat-
ics as a way to assimilate, organize, and trans-
form information into knowledge.21,22 A nurse
stated, “Before reaching the hospital, I review
everything in my mind, all the medication that
has been administered, all the interventions, the
situation the patient has been through.” An-
other nurse said, “I use the following mental
schematic: the reason the patient is being trans-
ferred, medication administered, IV line, vital
signs.” Another nurse said, “I don’t use any
method for organizing the information in my
head. Visual signs, oxygen therapy, IV line, uri-
nary catheter, the way the patient arrives… your
eyes pick all that up and you instantly memorize
it … What I do try to memorize is the medication
that’s been given.”
The health care professionals surveyed also
believed that an essential part of patient trans-
fers lies in hospital management dening who
should be responsible for taking handover. A
nurse stated, “When you work in different
places, then you see different receiving hospitals’
systems. There are hospitals where you are
directed to triage and you speak with a nurse,
hospitals where a physician comes out, hospitals
where nobody comes out and you have to go and
nd someone, because they might be busy with
other things, so I think it also depends on the
receiving hospital’s organization.” Other nurse
4Handover of Patients From Prehospital Emergency Services to EDs Journal of Nursing Care Quality
said, “Some aren’t wearing proper identication,
and I know some are nurses and others aren’t.”
Communication
There were 2 subtopics included here, commu-
nication with the appropriate person and the
need to apply communication techniques to
ensure the correct transmission of information
provided/received. Communication is dened as
the exchange of information between a speaker
and a listener.20 The participants highlighted the
importance of information being provided to
the health care professional who will be respon-
sible for the patient. They also underlined the
value of information being handed over between
professionals of the same role. A nurse stated
that is important to “know who I have to
handover to, which nurse, because sometimes
you don’t know the staff… they should identify
themselves clearly, to know who is giving and
who should be receiving the handover of the
patient.” Another nurse said, “Actually, PEMS
colleagues don’t seek out the nurse who will
be assigned to that patient, we have to ask.
Because there is no protocol, one has to insist to
get information … in PEMS, there is only one
opportunity for communication, and you need
all the complete details: diagnosis, procedures
performed and medication given, all those basic
things, but in a more accessible place, perfectly
visible.” A nurse added, “I think the nurse who
will be looking after the patient should be the
one receiving handover.” Handover is “a little
chaotic, because the PEMS nurse hands over
to a ED nurse who happens to pass by. I think
there should be an ofcially designated receiving
nurse.”
Only 2 participants, 1 PEMS and 1 ED nurse,
believed it necessary to check the information
received with a physician, “I ask the physi-
cian about any details I’ve missed, in order
to make the information to be handed over
complete.” The other nurse said, “I often lis-
ten to what the PEMS physician tells the ED
physician, since the information is more com-
plete than that provided by the nurse. Other
times, once the handover has been given. I com-
pare my information with that of the physician.”
Regarding communication techniques, partici-
pants were asked about their use of active listen-
ing techniques such as clarication, paraphras-
ing, and feedback.23, 24 A nurse stated, “People
respond afrmatively, as if they are listening to
you, but you don’t know if it’s an automatic re-
sponse, you don’t know if they are really cap-
turing the information or not. I think there is
a lack of feedback.” Another nurse said, “Of-
ten the nurse tells me the medication that’s been
given, and I repeat this back. I focus on what
seems important to me, but I don’t retain all the
information the nurse has told me, and a lot gets
lost.” A nurse added, “I use feedback: I repeat
what I can remember in case I’ve missed some-
thing.”In addition to verbal feedback, nurses use
nonverbal communication techniques as a tool
for conrming receipt of the message.
Clinical records
Three subtopics were identied: on the ver-
bal handover and written and digital medical
records. Clinical records are condential docu-
ments that contain patients’ clinical information.
This information includes educational and other
patient characteristics and constitutes an impor-
tant administrative element.25 Currently, this in-
formation is recorded either on paper or in a dig-
ital format; however, handover between PEMS
and the ED is transmitted verbally.
The interviewees underscored the need to sup-
port this verbal handover with a recorded format
without the need for duplicating information. A
nurse stated, “If it were backed up with a writ-
ten document it would be fantastic … an easy-
to-read document, not overly lengthy, in which
any interventions performed on patients, the rel-
evant past medical history, the medication given,
and the reason for the referral are recorded.”An-
other nurse said, “The referral form the physi-
cian receives actually includes a nursing sec-
tion, but it’s unreadable, with abbreviations.” A
nurse specied, “A handover form exclusively
for nurses isn’t necessary … the current form
could be modied … even if there were 2 copies:
one for the nurse and another for the physician,
because both should have access to the same
information.”
DISCUSSION
The present study described the key experiences
of Spanish PEMS and ED nurses regarding the
transfer of patients. In line with our results, a
range of authors describe the ideal transfer pro-
cess as a structured system, either on paper or
in a digital format, which allows the recording
and permanent storing of information to sup-
port the verbal handover and organize essential
00 2018 • Volume 0 • Number 0 www.jncqjournal.com 5
patient data. 5 ,11 ,26-28 To implement standardiza-
tion would reduce data loss, and improve pa-
tient safety and professional satisfaction.1,8,29-31
According to Dubosh et al,32 the use of check-
lists would reduce errors in care and memory.
The interviews highlighted the need to assign
an ED nurse to take handover, who should be
easily identiable by PEMS staff and involved in
the subsequent care of the patient. This concurs
with literature on handovers between health care
professionals and other individuals and fam-
ily members to improve relevant information
transferred.4,5,30,31,33 Information that should be
included in the handover process, which most
participants stressed, was patient identication,
reason for referral, medical history, procedures
performed, and medication administered. There
are several classication systems such as the
I-PASS (Illness severity, Patient summary, Action
list, Synthesis by receiver, Summary by receiver)
system for organizing data, which could be
used.33-35
To ensure an effective exchange of informa-
tion, participants consider the need for a good
communication skill. The individual behavior
during the communication processes is key to
the correct reception of messages in noisy, stress-
ful environments with constant interruptions.5
It is therefore important to have active listen-
ing techniques, which facilitate communication
and reduce barriers.4Consistent with Greenstein
et al,36 the communication techniques described
and used by the participants were feedback, clar-
ication, taking notes, and access to a handover
form. They recognized that ways to complete the
communication process were underutilized.
Limitations
The data collected reect the experience of PEMS
and ED nurses from the province of Alicante
(Spain). The entire PEMS have the same orga-
nization: ambulances’ teams are formed by the
physician, nurse, and technician, or by the nurse
and technician. Every team has to transfer the pa-
tient to the ED after their advanced live support,
and the nurse always has to be responsible for
the process. However, ndings may be general-
izable to other areas that do not possess similar
organization systems or characteristics.
CONCLUSIONS
The present study demonstrates the need to
standardize the patient transfer process between
PEMS and ED professionals, to improve commu-
nication, avoid data loss and adverse events, and
thus increase clinical safety. The essential infor-
mation to include in patient transfers is the rea-
son for referral, past history including any infor-
mation relevant to the case, drug allergies, and
procedures performed with an emphasis on drug
administration and response to treatment.
The following steps are proposed for perform-
ing adequate patient transfer: rst, identify the
receiving nurse for the patient; second, subse-
quent to presenting themselves, the PEMS nurses
should handover the relevant patient informa-
tion in the following order: patient identication,
reason for the referral, past medical history, and
baseline, whether they know each other, proce-
dures performed prior to arrival, and the patient
response to treatment; and third, the ED nurse
should conrm the correct receipt of all informa-
tion, repeating it back or asking questions and
requesting clarication as needed. Verbal com-
munication should be backed up at all times with
written material provided by the PEMS nurse.
The standardized patient transfer process be-
tween PEMS and ED nurses should be structured
to organize and store patient information. That
will help reduce errors in care and data loss, as
well as avoiding adverse events, and improving
patient safety and professional satisfaction.
REFERENCES
1. Johnson M, Sanchez P, Zheng C. The impact of an integrated
nursing handover system on nurses’ satisfaction and work
practices. J Clin Nurs. 2016;25(1/2):257-268.
2. Johnson M, Jefferies D, Nicholls D. Developing a mini-
mum data set for electronic nursing handover. J Clin Nurs.
2012;21(3/4):331-343.
3. Flink M, Tessma M, Cvancarova Småstuen M, Lindblad M,
Coleman EA, Ekstedt M. Measuring care transitions in Swe-
den: validation of the care transitions measure. Int J Qual
Heal Care. 2018;30(4):291-297.
4. American Academy of Pediatrics Committee on Pediatric
Emergency Medicine, Medicine ACOEPPE, Committee, Pe-
diatric ENA. Handoffs: transitions of care for children in the
emergency department. Pediatrics. 2016;138(5).
5. Dawson S, King L, Grantham H. Review article: improv-
ing the hospital clinical handover between paramedics and
emergency department staff in the deteriorating patient.
Emerg Med Australas. 2013;25(5):393-405.
6. Bost N, Crilly J, Wallis M, Patterson E, Chaboyer W. Clinical
handover of patients arriving by ambulance to a hospital
emergency department. A literature review. Int Emerg Nurs.
2010;18:210-220.
7. Riesenberg LA, Leisch J, Cunningham JM. Nursing hand-
offs: a systematic review of the literature. Am J Nurs. 2010;
110(4):24-34.
8. Agarwala AV, Firth PG, Albrecht MA, Warren L, Musch
G. An electronic checklist improves transfer and retention
of critical information at intraoperative handoff of care.
Anesth Analg. 2015;120(1):96-104.
6Handover of Patients From Prehospital Emergency Services to EDs Journal of Nursing Care Quality
9. Lo H-Y, Mullan PC, Lye C, Gordon M, Patel B, Vachani
J. A QI initiative: implementing a patient handoff checklist
for pediatric hospitalist attendings. BMJ Qual Improv Rep.
2016;5(1):1-6.
10. Mullan PC, Macias CG, Hsu D, Alam S, Patel B. A Novel
brieng checklist at shift handoff in an emergency depart-
ment improves situational awareness and safety event iden-
tication. Pediatr Emerg Care. 2015;31(4):231-238.
11. Jewell JA, Committee on Hospital Care. Standardiza-
tion of inpatient handoff communication. Pediatrics. 2016;
138(5):e20162681.
12. Bruno GM, Guimond ME. Patient care handoff in the
postanesthesia care unit: a quality improvement project. J
Perianesth Nurs. 2017:32(2):125-133.
13. Boat AC, Spaeth JP. Handoff checklists improve the re-
liability of patient handoffs in the operating room and
postanesthesia care unit. Paediatr Anaesth. 2013;23(7):
647-654.
14. Farhan M, Brown R, Vincent C, Woloshynowych M. The
ABC of handover: impact on shift handover in the emer-
gency department. Emerg Med J. 2012;29(12):947-953.
15. Klim S, Kelly AM, Kerr D, Wood S, Mccann T. Develop-
ing a framework for nursing handover in the emergency de-
partment: an individualised and systematic approach. J Clin
Nurs. 2013;22(15/16):2233-2243.
16. Di Delupis FD, Mancini N, di Nota T, Pisanelli P. Pre-
hospital/emergency department handover in Italy. Intern
Emerg Med. 2015;10(1):63-72.
17. Tong A, Sainsbury P, Craig J. Consolidated criteria for re-
porting qualitative research (COREQ): a 32-item checklist
for interviews and focus groups. 2007;19(6):349-357.
18. Abela JA. Las Técnicas de Análisis de Contenido: Una Re-
visión Actualizada. Sevilla, Spain: Fundacion Centro de Es-
tudios Andaluces; 2002:1-34.
19. Guba EG, Lincoln YS. Paradigmas en Pugna en la Investi-
gación Cualitativa. In: Denzin N, Lincoln I, eds. Handbook
of Qualitative Research. London, England: Sage; 1994:105-
117.
20. Real Academia Española. 2017 Diccionario de la Real
Academia de la Lengua Española. http://dle.rae.es/?w=
diccionario. Published 2017. Accessed January 17, 2018.
21. Muños-Gonzales JM, Ontoria Peña A, Molina-Rubio A. El
mapa mental, un organizador gráco como estrategia didác-
tica para la construcción del conocimiento. Magis Rev Int
Investig en Educ. 2011;3(6):343-361.
22. Villalustre Martínez L, Del Moral Pérez E. Mapas con-
ceptuales, mapas mentales y líneas temporales: objetos
“de” aprendizaje y “para” el aprendizaje en Ruralnet. Rev
Latinoam Tecnol Educ. 2010;9(1):15-28.
23. Galiana-Roch J. Enfermería Psiquiátrica. Barcelona, Spain:
Elsevier; 2016.
24. Cibanal J, Arce M, Carballal Balsa M, Arce Sanchez M. Téc-
nicas de Comunicación y Relación de Ayuda En Ciencias de
La Salud. 3rd ed. Barcelona, Spain: Elsevier; 2014.
25. Guzmán F, Arias CA. La historia clínica: elemento funda-
mental del acto médico. Rev Colomb Cir. 2012;27:15-24.
26. Manias E, Geddes F, Watson B, Jones D, Della P. Per-
spectives of clinical handover processes: a multi-site sur-
vey across different health professionals. J Clin Nurs.
2016;25(1/2):80-91.
27. Meisel ZF, Shea JA, Peacock NJ Dickinson ET, et al. Op-
timizing the patient handoff between emergency medical
services and the emergency department. Ann Emerg Med.
2015;65(3):310-317.
28. Jensen SM, Lippert A, Østergaard D. Handover of patients: a
topical review of ambulance crew to emergency department
handover. Acta Anaesthesiol Scand. 2013;57(8):964-970.
29. Balhara KS, Peterson SM, Elabd MM, et al. Implement-
ing standardized, inter-unit communication in an interna-
tional setting: handoff of patients from emergency medicine
to internal medicine. Intern Emerg Med. 2018;13(3):
385-395.
30. Abraham J, Kannampallil TG, Almoosa KF, Patel B, Patel
VL. Comparative evaluation of the content and structure
of communication using two handoff tools: implications for
patient safety. JCritCare. 2014;29(2):311.e1-311.e7.
31. Abraham J, Kannampallil TG, Patel B, Almoosa K, Patel VL.
Ensuring patient safety in care transitions: an empirical eval-
uation of a handoff intervention tool. AMIA Annu Symp
Proc. 2012;2012:17-26.
32. Dubosh NM, Carney D, Fisher J, et al. Implementation of
an emergency department sign-out checklist improves trans-
fer of information at shift change. JEmergMed. 2014;
47(5):580-585.
33. Heilman JA, Flanigan M, Nelson A, Johnson T, Yarris LM.
Adapting the I-PASS program for emergency department
inter-shift handoff. Western J Emerg Med. 2016;17(6):756-
761.
34. Johnson M, Jefferies D, Nicholls D. Exploring the structure
and organization of information within nursing clinical han-
dovers. Int J Nurs Pract. 2012;18(5):462-470.
35. Iedema R, Ball C, Daly B, et al. Design and trial of a
new ambulance-to-emergency department handover proto-
col: “IMIST-AMBO.” BMJ Qual Saf. 2012;21(8):627-633.
36. Greenstein EA, Arora VM, Staisiunas PG, Banerjee SS, Far-
nan JM. Characterising physician listening behaviour during
hospitalist handoffs using the HEAR checklist. BMJ Qual
Saf. 2013;22(3):203-209.
