Q Manage Health Care Vol. 18, No. 2, pp. 103–114 c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Implementation of a Automation System (Robotics) to Ensure Safety at Norwalk Hospital

Robert J. Bepko, Jr, BS, MHA, RPh; John R. Moore, BS, MHA, RPh; John R. Coleman, PhD

This article reports an intervention to improve the CURRENT INDUSTRY TRENDS quality and safety of hospital patient care by introducing the use of pharmacy robotics into the The Institute of Medicine reported in 1999 that medication distribution process. Medication safety there are more than 98 000 preventable medical er- is vitally important. The integration of pharmacy rors that occur annually in US Hospitals, that 10% robotics with computerized practitioner order entry of hospitalized patients suffer medication-related in- and bedside medication bar coding produces juries, and that more than 7000 patients die annu- ally because of medication errors.1 A recent study a significant reduction in medication errors. found that the leading cause of anxiety for patients is The creation of a safe medication—from initial the fear of suffering a medication error during their ordering to bedside administration—provides hospital stay. Evidence suggests this fear may be jus- enormous benefits to patients, to health care tified. Researchers who observed nurses delivering providers, and to the organization as well. to patients in 36 health care facilities in the Greater Atlantic and Denver metropolitan areas made some startling findings. Almost 1 in 5 medi- cations was given erroneously, and 7% of the mis- takes were potentially harmful.2 Investigators at Har- vard found that most medication errors occur either when a physician inaccurately ordered a medication (39%) or when a nurse administered a mistak- enly (38%). More importantly, the Harvard study also revealed that, luckily, almost one-half of all inaccu- rate physician orders were intercepted by nurses and before these mistakes reached the pa- tient. In contrast, only 2% of nurses’ errors when ad- ministrating a medication were intercepted, making the risk of error far greater at the patient’s bedside.3 Multiple studies within the medical literature con- sistently demonstrate that more than 30% of all

Author Affiliations: Corporate Pharmacy Services, Nor- walk Hospital, Connecticut (Messrs Bepko and Moore); and Ancell School of Business, Western Connecticut State University, Danbury (Dr Coleman). Corresponding Author: Robert J. Bepko Jr, BS, MHA, Key words: automation, bar code , medication RPh, Corporate Pharmacy Services, Norwalk Hospital, safety, prescription error reducing Connecticut.

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Figure 1. Dispensing error rates. medication errors and adverse drug events (ADEs) and 12 technicians to provide pharmacy services 24 occur at the administration stage of the medication hours per day, 7 days per week. The hospital has distribution process. Systems exist that use bar code a manual, labor-intensive medication distribution technology to ensure accurate medication selection and administrative process. A nationwide shortage and dispensing by the .4 Other systems of pharmacists and increased regulatory demand exist that use bar code and wireless communication (The Joint Commission) prompted the pharmacy to safely administer medications at the management team to investigate means to deliver patient’s bedside. These systems can drastically im- and improve pharmacy services to its patients. prove the accuracy of medication administration as well as automate the documentation process. Unfor- THE EVALUATION PROCESS tunately, although many such systems are marketed, very few have been effectively implemented in hos- The pharmacy department dispenses approxi- pitals to date.5–8 mately 5500 doses of medications in a 24-hour pe- riod. Pharmacy technicians used computer-generated THE SETTING OF THE PROBLEM lists to pick patient medications. These medications were then placed in a designated patient cassette. Norwalk Hospital is a private, nonprofit, acute Pharmacists using the same medication lists checked care hospital located in the southwest suburb of the patient cassettes to ensure the accuracy of the Norwalk, Connecticut. The city of Norwalk is in technicians’ work. The process was tedious and time- Fairfield County, one of the most affluent counties consuming. As highly trained professionals, the phar- in the country. Founded more than 100 years ago, macists quickly become bored when not performing the hospital serves 50 000 residents of the city and patient-centered activities (drug information, kinetic 300 000 residents in the 5 neighboring communi- consultation, and drug therapy reviews). ties. The hospital is supported by private payers As a check on this process, an additional pharma- (insurance companies and health maintenance or- cist check on the medication cassettes was conducted ganizations), federal payments (Medicare), and state over a 28-day period to measure the accuracy of the reimbursements (Medicaid) as well as by private and filling and dispensing process. The dispensing error community donations usually for a specific cause rate was calculated at the end of this period (see Fig 1 or project. The hospital employs 17 pharmacists and Table 1). The data revealed that even after a Implementation of a Pharmacy Automation System 105

Table 1 single medication travels through many steps (and health care providers) between the patient’s present- ERRORS RATE OF PHARMACIST-CHECKED a ing a condition and the time that patient actually re- MEDICATION CARTS ceives that medication. Figure 2 reviews the medi- cation use system and highlights its vulnerabilities. Day Weekday Error rate, % The left side of the illustration shows the vulnera- 1D Monday 3.00 bilities of a manual system approach to the medica- 2D Tuesday 3.50 tion process. Poor handwriting, transcription errors, 3D Wednesday 2.00 and incorrect visual checks all conspire to prevent 4D Thursday 1.00 the institution from guaranteeing that the patient re- 5D Friday 3.90 6D Saturday 4.40 ceives the Five Rights of medication administration. 7D Sunday 4.80 The right side of the illustration shows that an auto- 8D Monday 2.70 mated process has great potential to reduce errors and 9D Tuesday 2.20 guarantees that each patient receives the Five Rights 10D Wednesday 2.00 of medication administration. 11D Thursday 3.10 12D Friday 2.60 Developments in information technologies, includ- 13D Saturday 3.80 ing bar coding, computerized practitioner order en- 14D Sunday 3.40 try, pharmacy computer and automation systems, 15D Monday 3.60 analytical tools, and error reporting instruments, 16D Tuesday 3.40 provide opportunity for a system approach to pro- 17D Wednesday 2.80 cess improvement. The Agency for Healthcare Re- 18D Thursday 2.10 19D Friday 2.50 search and Quality estimates that hospitals can save 20D Saturday 3.70 $500.000 in direct costs by using these processes. Pa- 21D Sunday 2.90 tient safety must be the primary focus of any system 22D Monday 3.00 approach to process improvement. To assess the po- 23D Tuesday 2.50 tential impact (real and relative) of any solution to re- 24D Wednesday 1.20 25D Thursday 1.70 duce medical errors, the medication use process and 26D Friday 3.30 respective vulnerability points must be reviewed in 27D Saturday 3.40 the context of the entire system. 28D Sunday 3.30 The Institute of Medicine report suggests that Average 2.92 the causes of most errors are “system errors” rather than individual behaviors or intent. Therefore, solu- aConducted over a 28-day period, average 5500 doses per day. tions to medical error and their respective “system failures” must focus on identifying system failure modes and creating reliable safeguards. Tables 2 and pharmacist had done the standard check of the 3 describe various vulnerabilities in the medication medication cassettes, there were, on average, 160 use process. The percentage of ADE interceptions medication variances (2.9%). When the staffing was is based on the portion of the system with the least reduced on the weekends, the error rate was higher, redundancy and double checks. up to 264 medication variances (4.8%). After reviewing its medication variance data, the National research consistently finds that 1 of every pharmacy department decided to attempt to automate 5 doses administered results in medication error. Nor- the dispensing function, beginning with the process walk Hospital’s data revealed a medication variance of bar coding medications to facilitate point-of-care rate of 6.1 per 1000 doses billed. bar coding medication administration. The project Errors are common in health care systems because was presented as a 2-phased project in conjunction of the complex cognitive mechanisms involved.9 A with the nursing and information departments. 106 QUALITY MANAGEMENT IN HEALTH CARE/VOLUME 18, ISSUE 2, APRIL–JUNE 2009

Figure 2. Manual vs computerized practitioner order entry system. IV, intravenous. aVery vulnerable to errors. bPotential for greatly reducing errors.

THE APPROVAL PROCESS a project of this magnitude should wait for the new CEO and management team. The process to recruit Once it was decided to move ahead with automa- a new CEO has not even started. The pharmacy staff tion was made, we had to find a sponsor in the institu- feared that the project would be tossed aside once tion to champion its cause. It proved to be a difficult a new management team was in place. (It was 18 task. The Board of Trustees had decided to replace months before the new CEO arrived.) The pharmacy the hospital’s CEO. Pharmacy management spoke to department managers enlisted the help of the out- several senior management members to champion going CEO, who suggested meeting with the Chair- the project; no one expressed interest, arguing that person of the Planning Committee of the Board of Implementation of a Pharmacy Automation System 107

Table 2 MEDICAL ERRORS AND ERROR RATES

NATIONAL DATA SHOWING MEDICATION ERRORS, National research has found that 1 of every 5 DISTRIBUTION, AND NUMBER PREVENTEDa doses administered results in a medication error. The Food and Drug Administration estimates that 40% Medication use Percentage of step and Distribution adverse drug to 50% of medical errors involve Food and Drug common types of errors event intercepted Administration–regulated products (eg, , blood of errors by step “prevention”b and blood products, vaccines, and devices).10 Nor- walk Hospital’s data revealed a medication variance Prescribing 39% 48% Transcribing 12% 33% rate of 6.1 per 1000 doses billed. In 2001, the phar- Dispensing 11% 34% macy implemented clinical pharmacists to provide Administering 38% 2% direct intervention during medical rounds at Nor- walk Hospital.11 aAdapted from Leape et al.1 bPercentage of interception (realized before harm) due to least amount of support from redundancy and double checking. Bar MEDICATION MANAGEMENT PROCESS code medication administration provides the double check. A systems approach to medication errors includes Trustees, explaining the project, and asking him to framing a solution to encompass the complexity of champion it. Subsequently the Chairperson visited the medication system; the importance of error detec- the department and witnessed how medications were tion and analysis; and the respective roles of physi- distributed to patients. He was stunned at the manual cians, nurses, and pharmacists in the medication use nature of the process and saw opportunities to im- process.12 Table 4 contains the current status and the prove patient care with automation in the pharmacy future status of the medication management process. department. The trustee championed the project and It contains the responsibility of the pharmacy depart- guided the process of assembling data to present to ment, the role and responsibility of the physicians the planning and finance committees of the board. and clinical teams, and the role of the pharmacists Pharmacy management met 6 times over a 2-week and registered nurses in the medication management period to present information on medical errors and process. error rates to the board for its edification. BAR CODING OF MEDICATIONS Table 3 ENSURES PATIENT SAFETY

MEDICAL ERRORS FOR NORWALK HOSPITAL— Automation of the pharmacy distribution process = (FEBRUARY 2001–MARCH 2004; n 300) and the bar coding of medications and the patients will improve inventory management, via automated Medication use step, Distribution of purchasing, distribution, and management. It will types of error errors by type also increase pharmacist participation in the pre- Wrong patient 7% scribing process. The automated repackaging with Wrong drug 13% bar code labeling also supports and provides for au- Wrong dose 27% tomated cart filling with bar code verification, which Wrong time/frequency 10% allows automated restock via bar code label and Wrong route 4% Medication omission 32% patient-specific cart refill. This eliminates manual Medication allergy 3% cart fill and checking (see Table 5). Near miss 4% Delivering a bar code–labeled medication prod- uct allows the clinician nurse to use bar code 108 QUALITY MANAGEMENT IN HEALTH CARE/VOLUME 18, ISSUE 2, APRIL–JUNE 2009

Table 4

THE MEDICATION MANAGEMENT PROCESSES

Medication management process Current state Future state

Selecting and procuring: Responsibility of the pharmacy department through the Pharmacy and Therapeutics Committee a. Establish formulary and inventory a. Inventory management of 3500 a. Improved inventory management b. Maintain appropriate inventory line items b. Automated ordering process b. Manual product selection (bulk • Bar code checking for accuracy vs unit dose) c. Projected 18 inventory turns c. 12 inventory turns annually annually Prescribing: Responsibility of physician and clinical team, including clinical pharmacist a. Assess patient and determine a. Physician handwritten a. Prescriber medication order entry need for drug therapy medication orders • Pharmacist verification b. Clinical team optimizes • Order entry by nurse or unit streamlined therapeutic selection secretary b. Increase pharmacy participation in c. Order the medication b. Pharmacist review and the prescribing process verification • Pharmacist involved in • Pharmacy participation in prescribing process is prescribing process (rounds) recommended by The Joint in intensive care unit and team Commission and has shown a care floors decrease in adverse drug events in various studies Preparing and dispensing: Responsibility of the pharmacist a. Select, prepare, and purchase a. Manual (re)packaging of 40% of a. Automated repackaging providing products items (bulk purchases) bar code labeling • Dispense 5500 unit doses per • Manual inventory process b. Automated cart filling with bar code day b. Manual cart filling process for 12 verification b. Verification of order patient care units • Automated restock via bar code • Medication order checking • Visual checking of all packaging label c. Delivered daily to patient care and cart fills by pharmacists • Patient-specific cart fill areas 365 days per year • Eliminates the manual cart fill and checking Administering: Responsibility of the registered nurse a. Adherence to the “Five Rights” of a. Manual/visual patient a. Deliver a bar code–labeled medication administration identification medication to patient care areas • Right patient b. Manual/visual identification of (phase 1) • Right drug medication b. Develop an implementation plan for • Right dose c. Manual charting on electronic (phase 2): • Right time/frequency medication administration • Positive patient identification • Right route record, resulting in an average of via bar code technology 150 uncharted medications per • Positive medication identification day via bar code device • Concurrent and accuracy of charting, therefore improved work flow and documentation Monitoring: Responsibility of the clinical team a. Assess patient response to a. Pharmacy involved in Increase pharmacy monitoring therapy, report reactions and retrospective monitoring prospective pharmacy monitoring events, optimize therapy Implementation of a Pharmacy Automation System 109 $876 788.40 $1 362 468.40 64.8 11.4 104.8 16.4 One-time inventory savings 230 766.67 1 341 871.4 $1 681 847.40 114.8 20.2 142.8 23.6 Current state with manual dispensing Future state: Automation and bar code administration including dispensing and bar code salary day salary day salary $1 112 958.00 $1 355 798.00 36.811.2 6.5 $627 274.40 2.0 $190 909.6084.0 36.8 14.8 11.2 6.5 $627 274.40 2.0 $190 909.60 36.8 7.0 6.5 $627 274.40 1.2 $119 318.50 28.0 4.9 $158 410.00 54.0 9.5 $305 505.0 20.0 3.5 $113 150.00 104.0 17.2 InjectionTotal 250 000.00 551 000.00 Injection Total 250 000.00 Injection 551 000.00 Total 250 000.00 320 233.33 Activity Current state visual inspection of bar coding verification scanning verification dispensing Totals Medication order Cart fill verificationRPh medication SubtotalsCart FillingRepackaging medications 8.0 4.0 1.4 $136 364.00 56.0 24.0 0.7 $22 630.00 9.9 12.8 4.2 $954 548.00 $135 780.00 2.2 16.0 $218 182.40 60.8 38.0 2.8 10.7 $90 520.00 1.0 $1 036 366.40 6.7 $214 985.00 0.2 8.0 44.8 $17 045.50 12.0 7.9 1.4 $763 638.40 $45 260.00 2.1 $67 890.00 Pharmacist Technician Totals Department RPh FTE TotalsDepartment TECHFTE Totals 76.0 12.3 $1 197 388.00 88.8 14.2 $1376 342.4 84.8 12.9 $1 249 318.40 Table 5 MEDIACATION CART FILL AND STAFFING COMPARISONS Abbreviations: FTE, full-time equivalent; RPh, registered pharmacist; TECHFTE, pharmacy technician full-time equivalent. I. Inventory (9-30-03) Oral (30-day supply) 301 000.00 Oral (30-day supply) 301 000.00 Oral (7-day supply) 70 233.33 II Cart filing process Hours per day FTE Approx. annual Hours per FTE Approx. annual Hours per FTE Approx. annual III. Clinical pharmacist rounds 20.0 2.5 $242 840.00 28.0 3.5 $339,976.00 40.0 5.0 $485 680.00 110 QUALITY MANAGEMENT IN HEALTH CARE/VOLUME 18, ISSUE 2, APRIL–JUNE 2009

administration of medication at the bedside and pro- pharmacist throughout the medications use process vide an error-free drug delivery system. helps ensure continuity of care and may minimize Bar coding medications improves patient safety the risk, lower the cost, and improve the outcomes by improving the accuracy of (positive) patient associated with the drug therapy. identification and improving the identification of The hospital pharmacy staff record pharmaceutical the patients’ specific medication. Positive patient care interventions daily in the Pharmaceutical Care identification is mandated in The Joint Commission Intervention database. These interventions are in- National Patient Safety Goal No. 1. Recently, The tended to improve patient outcome and/or exemplify Joint Commission proposed a requirement for bar reducing the costs of therapy. A sample of the phar- code technology in the medication administration macist interventions is listed in Table 7. There were process by 2007. 1510 pharmacy interventions focused on improving Bar coding medications ensures that all patient patient outcomes for the 5-month period (January 1, medication administration is documented in the pa- 2004, through May 31, 2004). There were 834 phar- tient’s record, providing more accurate documenta- macy interventions focused on reducing the costs tion and capture of patient care costs. of therapy for the 5-month period (January 1, 2004, through May 31, 2004). FINANCIAL BENEFITS OF BAR CODING MEDICATION THE OUTCOMES

The financial benefits of using bar coding medica- The Planning and Finance Committees approved tion are found in Table 6. They include: the purchase of the pharmacy robotics project. The • increase capture of charges, via automated chart- robotics system was ordered in the pharmacy. The ing; software interface between the Cerner Information • prevent ADEs that lengthen the average patient System and the McKesson Rx Robot was tested. The stay by 2.2 days at a cost estimated to be approx- filling of patient medication cassettes by the robot imately $4600 per event; was initiated on June 22, 2005, with the intent to im- • cost avoidance of the average jury award for med- plement one nursing unit and convert the rest of the ication error, which had reached $636 844 per patient care areas at the rate of one additional unit award in 2000; every 3 days. After the first day of filing with the • positive patient identification; robot, and with no problems, we converted the rest • complete patient record; and of the hospital the following day. The conversion to • able to get the attention of the community be- robotic fill allowed us to operate more efficiently. As cause it directly interacts with the patient. had been described to the board, additional full-time equivalents were freed up and the pharmacy depart- NORWALK HOSPITAL PHARMACY ment quickly took on additional clinical responsibil- INTERVENTIONS ities in the hospital (see Fig 2). Pharmacist responsibilities were redesigned and More complex inpatient care resulting from new expanded to improve the quality and safety of technology, higher acuity of illness, and shorter hos- the medication use process. Pharmacy leaders ini- pital stays are placing heavier demands on health tiated and coordinated the process of medica- care practitioners. These trends are reflected in the tion reconciliation—a recently defined Joint Com- increasing number, types, and cost of prescribed mission National Patient Safety Goal—across the drugs. The selection, administration, and monitoring organization. of these drugs may be performed best by using an in- Medication reconciliation is the process of review- terdisciplinary approach. The direct involvement of a ing patients’ medications that they take at home, Implementation of a Pharmacy Automation System 111

Table 6

ESTIMATED ANNUAL COSTS RELATED TO ADEs AND ANNUAL COST OF AVOIDANCE

A. Estimated annual hospital costs related to preventable ADEs 1. Number of hospital admissions (per year) $20 210 2. Estimated number of total preventable ADEs (per year) $281.68 3. Estimated hospital cost attributed to preventable ADEs (per year) $5000 4. Total annual cost related to preventable ADEs (A2 × A3) $1 408 400 B. Estimated annual costs for technology 1. Software license fee (perpetual license, one-time fee) 2. Monthly support fees 3. Hardware cost 4. Installation fee (for hardware) 5. Implementation/consulting cost for system configuration 6. Training and implementation (staffing) 7. Total cost for technology (sum B1-B6) $710 490 C. Annual cost avoidance using technology to address medication errors 1. Preventable ADE due to prescribing (eg, CPOE, pharmacy information system) = (39%) × (A4) $549 276 2. Preventable ADE due to transcribing (eg, order management imaging system) = (12%) × (A4) $169 008 3. Preventable ADE due to dispensing (eg, robotics, automated carts) = (38%) × (A4) $154 924 4. Preventable ADE due to administration (eg, nursing point-of-care systems) = (38%) × (A4) $535 192 5. Total annual cost savings (C1 + C2 + C3 + C4) $1 408 400

Abbreviation: ADE, adverse drug event; CPOE, computerized practitioner order entry.

Table 7

COST REDUCTIONS FOR PHARMACY INTERVENTION FOR JANUARY 2004 THROUGH MAY 2004

Total for Average cost Estimated reduction Projected 5-month period saving per in pharmaceutical annual (Jan–May 2004) interventiona costs for 5 months reductions

Improving patient outcome Adjust amount of medication patient receives 467 $89 $41 563 $99 751 Change the frequency/timing of patients’ 199 $89 $17 711 $42 506 medications Provide clinical monitoring and therapeutic 199 $89 $75 116 $180 278 consultations, including drug interaction and allergy screening 1510 $134 390 $322 536 Reducing cost of therapy Therapeutic substitution 264 $80 $21 120 $50 688 Change route (intravenous to oral) 183 $80 $14 640 $35 136 Recommend the addition or deletion of 387 $80 $30 960 $74 304 medications 834 $66 720 $160 128 Total $482 664 aThe average cost savings per intervention are based on literature. 112 QUALITY MANAGEMENT IN HEALTH CARE/VOLUME 18, ISSUE 2, APRIL–JUNE 2009

Figure 3. Medication process diagram. the medications they received in the hospital, and ten for warfarin for the patient upon discharge. The the medications prescribed at the point of discharge physician instructed the patient to resume all pre- from the hospital. This coordination prevents seri- vious medications that he or she was taking before ous duplication of therapy. A patient may take one admission. Unknowingly, the patient returned home medication in a certain therapeutic class at home. and continued taking warfarin along with the new Upon admission, the patient may receive a similar prescription for warfarin leading to an overdosage. product in the same therapeutic class based on a This preventable occurrence resulted in readmission hospital-approved drug formulary. When a patient is of the patient to the hospital. Under the new system, discharged, it has to be decided which of the differ- each patient’s medication history is reviewed within ent (but similar) products will be continued at home. 24 hours of admission by a pharmacist. The pharma- The incident that follows illustrates how the process cist reviews the patient’s chart and conducts inter- of medication reconciliation can lead to increased pa- views with the patient and family members to obtain tient safety. A patient who was taking a daily dose of the name and strength of the medications being taken. 5 mg of the anticoagulant warfarin (Coumadin) was This information is loaded into the Cerner database admitted to the hospital. In the hospital, the pre- and is available to all clinicians. When the patient scriber ordered 7.5 mg of warfarin to be taken daily. is scheduled for discharge, the prescriber reviews Problems arose when a new prescription was writ- this information and selects those medications to Implementation of a Pharmacy Automation System 113

continue. Medications that are not checked off are 1, 2007). This system assists the nurse in giving the discontinued. The database then generates a current right medication to the right patient. The nurse scans and legible medication list. This list is referred to as a the patient’s wristband and the patient’s medication W-10 for patients going to extended care facilities. list is displayed on a portable computer screen. The The Multidisciplinary round (MDR) was initiated nurse selects the scheduled medication and scans to ensure that patients are prescribed appropriate the medication table. With a positive match, the nurse medications and evidence-based procedures proven then administers the medication to the patient. The to improve quality of care for hospital patients. The administration is recorded into the patient’s perma- MDR occurs 3 times a week. In approximately 90 min- nent medical record, and the patient is billed for the utes, the care of 120 patients is reviewed by a team dose. composed of doctors, nurses, pharmacists, and case This is the last step in improving medication safety managers.12 All patients are assessed to ensure that as outlined in the medication process diagram in the standard of care is met. For example, if the pa- Figure 3. tient suffered a myocardial infarction, has the patient been placed on a β-blocker drug? Is the patient re- CONCLUSIONS ceiving low-dose aspirin? Has the patient received smoking-cessation training if he or she smokes? If The use of automation in health care has the poten- admitted for pneumonia, has the patient received a tial to increase the quality of patient care in the hos- dose of pneumococcal vaccine? If the patient is re- pital setting. Automation not only ensures that the ceiving intravenous antibiotics, can the patient be Five Rights of medication guidelines for each patient switched to an oral agent? The database containing are ensured, it also frees up health care professionals pharmacist interventions reveals that the pharmacist to perform tasks that improve patient care in other involved in MDR makes recommendations to patient ways. care plans approximately 30% of the time (36 pa- tients per MDR). REFERENCES

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Errata Possible Unintended Consequences of a Focus on Performance: Insights Over Time From the Research Association of Practices Network: Errata The corresponding author for the article should be Kurt Stange, Department of Family Medicine, Research Division, Case Western Reserve University, 11001 Cedar Ave, Ste 306, Cleveland, OH 44106 ([email protected]). In addition, the study grant numbers listed were incorrect. The study was supported by grants from the National Cancer Institute (1RO1 CA060862, 2RO1 CA060862, 4R01 CA060862, 5RO1 CA060862, R25T-CA111898). Reference Weyer SM, Bobiak S, Stange KC. Possible unintended consequences of a focus on perfor- mance: insights over time from the research association of practices network. Qual Manag Health Care. 2008;17(1):47–52.