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nte
rna
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l J
o
urna
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Vo
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1912
J
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h
ttp
:
//
ijp
h
s
.
ia
esco
r
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co
m
Patient
sa
fet
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c
ult
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a media
tor
bet
w
een h
ea
lthca
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nnel's ps
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nto
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.
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sy
c
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l
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p
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rm
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t
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p
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d
p
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tc
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e
s.
Th
is
st
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d
y
in
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sti
g
a
tes
th
e
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lati
o
n
sh
i
p
b
e
twe
e
n
p
sy
c
h
o
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g
ica
l
e
m
p
o
we
rm
e
n
t
(P
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a
n
d
p
a
ti
e
n
t
o
u
tco
m
e
(
P
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m
e
d
iate
d
b
y
p
a
ti
e
n
t
sa
fe
ty
c
u
lt
u
re
(P
S
C).
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c
ro
ss
-
se
c
ti
o
n
a
l
su
rv
e
y
st
u
d
y
wa
s
c
o
n
d
u
c
ted
in
p
ri
v
a
te
h
o
sp
i
tals
a
c
c
re
d
it
e
d
b
y
Jo
i
n
t
Co
m
m
issio
n
I
n
tern
a
ti
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l.
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to
tal
o
f
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e
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lt
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c
a
re
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e
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s
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ti
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ip
a
n
ts
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m
e
t
t
h
e
re
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u
irem
e
n
ts
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o
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y
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istr
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t
h
e
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e
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n
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ires
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0
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3
.
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ig
n
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c
a
n
t
re
su
lt
s
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ly
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e
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p
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l
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st
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u
a
re
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stru
c
tu
ra
l
e
q
u
a
ti
o
n
m
o
d
e
li
n
g
(S
E
M
).
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e
d
ime
n
sio
n
a
li
ty
o
f
P
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a
n
d
P
S
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wa
s
a
ss
e
ss
e
d
b
y
a
n
e
w
m
e
th
o
d
t
h
a
t
is
a
d
isjo
in
t
two
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sta
g
e
a
p
p
ro
a
c
h
.
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h
e
ro
le
o
f
P
S
C
w
a
s
fo
u
n
d
t
o
f
u
ll
y
m
e
d
iate
t
h
e
p
o
sit
iv
e
re
latio
n
sh
i
p
b
e
twe
e
n
p
sy
c
h
o
l
o
g
ica
l
e
m
p
o
we
rm
e
n
t
a
n
d
p
a
ti
e
n
t
o
u
tco
m
e
(
=
0
.
4
3
6
,
p
-
v
a
lu
e
<
0
.
0
5
,
CI
9
5
%
).
Th
e
d
irec
t
re
latio
n
b
e
twe
e
n
P
E
with
P
O
c
a
n
n
o
t
b
e
e
sta
b
li
sh
e
d
(
p
-
v
a
lu
e
>
0
.
0
5
)
.
Th
is
st
u
d
y
c
o
n
tri
b
u
tes
to
g
r
o
win
g
th
e
v
a
lu
e
o
f
d
e
v
e
l
o
p
i
n
g
a
sa
fe
ty
c
u
lt
u
re
a
n
d
t
h
e
fu
n
c
ti
o
n
o
f
p
sy
c
h
o
lo
g
ica
l
e
m
p
o
we
rm
e
n
t
in
h
e
a
lt
h
c
a
re
sta
ff
to
e
n
h
a
n
c
e
p
a
ti
e
n
t
o
u
tco
m
e
s.
K
ey
w
o
r
d
s
:
Hea
lth
ca
r
e
Ho
s
p
ital
Patien
t
o
u
tco
m
e
Patien
t
s
af
ety
cu
ltu
r
e
Ps
y
ch
o
lo
g
ical
e
m
p
o
we
r
m
en
t
T
h
is i
s
a
n
o
p
e
n
a
c
c
e
ss
a
rticle
u
n
d
e
r th
e
CC B
Y
-
SA
li
c
e
n
se
.
C
o
r
r
e
s
p
o
nd
ing
A
uth
o
r
:
E
ld
aa
Prisca
R
ef
ian
ti Su
tan
to
Dep
ar
tm
en
t o
f
Ho
s
p
ital A
d
m
in
is
tr
atio
n
,
Gr
ad
u
ate
Sch
o
o
l o
f
Ma
n
ag
em
en
t
,
Pelita
Har
ap
a
n
Un
iv
er
s
ity
J
ak
ar
ta,
I
n
d
o
n
esia
E
m
ail:
eld
aa
p
r
is
ca
@
g
m
ail.
co
m
1.
I
NT
RO
D
UCT
I
O
N
Patien
t saf
ety
i
s
th
e
m
ain
g
o
al
in
d
ev
elo
p
in
g
h
ea
lth
ca
r
e
s
y
s
tem
s
wo
r
ld
wid
e,
esp
ec
ially
in
d
ev
elo
p
in
g
co
u
n
tr
ies
with
in
ad
eq
u
ate
h
ea
lth
ca
r
e
f
ac
ilit
ies
[
1
]
,
[
2
]
.
Patien
t
s
af
ety
is
v
er
y
im
p
o
r
tan
t
to
b
e
im
p
lem
e
n
ted
in
h
o
s
p
itals
,
as
h
ea
lth
f
ac
ilit
ies
h
an
d
le
th
e
m
o
s
t
p
atien
ts
with
v
ar
io
u
s
c
o
m
p
lex
ca
s
es
wh
er
e
th
e
p
o
s
s
ib
ilit
y
o
f
m
ed
ical
er
r
o
r
s
is
g
r
ea
ter
.
T
h
er
ef
o
r
e
,
o
n
e
o
f
t
h
e
h
o
s
p
ita
l's
d
u
ties
is
to
m
ak
e
p
atien
t
s
af
ety
a
h
o
s
p
ital
o
r
g
an
izatio
n
al
b
eh
a
v
io
r
.
I
m
p
l
em
en
tin
g
a
p
atien
t
s
af
ety
c
u
ltu
r
e
in
h
o
s
p
itals
ca
n
im
p
r
o
v
e
t
h
e
q
u
ality
o
f
s
er
v
ic
e
an
d
p
atien
t
o
u
tco
m
es
[
3
]
,
[
4
]
.
Hea
lth
ca
r
e
m
an
a
g
em
en
t
t
o
d
a
y
is
m
o
r
e
ac
co
u
n
tab
le,
f
i
n
an
c
ially
an
d
s
o
cially
,
f
o
r
a
d
v
er
s
e
e
v
en
ts
with
in
th
ei
r
h
ea
lth
ca
r
e
o
r
g
an
izatio
n
an
d
th
e
o
v
er
all
p
atien
t
ex
p
er
ien
c
e.
T
h
e
g
o
v
er
n
m
e
n
t
an
d
p
u
b
lic
s
en
tim
en
t
h
av
e
ch
an
g
ed
f
r
o
m
to
ler
atin
g
h
u
m
an
er
r
o
r
as
in
ev
itab
le
to
ch
allen
g
in
g
h
o
s
p
ital
m
an
ag
em
en
t
to
im
p
r
o
v
e
h
ea
l
th
ca
r
e
s
y
s
tem
s
th
at
r
e
s
u
lt
in
er
r
o
r
an
d
/
o
r
a
n
eg
ativ
e
p
atie
n
t
ex
p
er
ien
ce
.
T
h
e
s
h
if
tin
g
o
f
th
is
u
n
d
er
s
tan
d
in
g
m
ak
es
it
im
p
o
r
tan
t
to
r
ea
lize
t
h
e
ess
en
ce
o
f
p
atien
t
s
af
ety
cu
ltu
r
e
an
d
its
im
p
ac
t
o
n
p
atien
t
o
u
tco
m
es
[
5
]
.
T
h
e
W
o
r
ld
Hea
lth
Or
g
an
izatio
n
(
W
HO)
n
o
tes
th
at
a
p
p
r
o
x
i
m
ately
1
0
m
illi
o
n
p
e
o
p
le
wo
r
ld
wid
e
g
et
p
r
ev
en
tab
le
in
ju
r
ies
o
r
d
ea
th
y
ea
r
ly
d
u
e
to
m
e
d
ical
in
ter
v
e
n
tio
n
.
Pre
v
en
tin
g
h
ea
lth
ca
r
e
e
r
r
o
r
s
a
n
d
r
ed
u
cin
g
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J
Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
P
a
tien
t sa
fety
cu
ltu
r
e
a
s
a
me
d
ia
to
r
b
etw
ee
n
h
ea
lth
c
a
r
e
…
(
E
ld
a
a
P
r
is
ca
R
efia
n
ti S
u
ta
n
to
)
1913
d
am
ag
e
ar
e
b
ec
o
m
in
g
th
e
b
asic
co
n
ce
p
ts
o
f
p
atien
t
s
af
ety
d
ev
elo
p
m
en
t
[
6
]
.
I
n
I
n
d
o
n
esia,
n
atio
n
al
r
ep
o
r
tin
g
d
ata
o
f
Patien
t
I
n
cid
e
n
ts
in
h
o
s
p
itals
h
av
e
y
et
to
b
e
f
u
lly
r
e
p
o
r
ted
r
o
u
tin
el
y
b
y
h
o
s
p
itals
.
Hen
ce
,
d
ata
r
elate
d
to
p
atien
t
s
af
ety
in
ci
d
en
ts
ar
e
s
till
n
o
t
wid
ely
av
ailab
le
[
7
]
,
[
8
]
.
T
h
e
last
in
cid
en
t
r
ep
o
r
ted
b
y
th
e
I
n
d
o
n
esia
n
Min
is
tr
y
o
f
Hea
lth
,
w
h
ich
th
e
r
ep
o
r
tin
g
o
f
p
atien
t
s
af
ety
ev
e
n
ts
h
as
in
cr
em
en
t f
r
o
m
2
0
1
8
t
o
2
0
1
9
,
f
r
o
m
1
,
4
8
9
ca
s
es to
7
,
4
6
5
ca
s
es.
Patien
t
s
af
ety
m
u
s
t
b
e
u
n
d
er
s
to
o
d
a
n
d
n
o
t
lim
ited
to
a
v
o
id
in
g
h
az
ar
d
s
s
u
ch
as
in
f
ec
tio
n
,
m
alf
u
n
ctio
n
o
f
m
ed
ical
d
e
v
ices,
tr
au
m
a
o
r
ac
cid
en
ts
,
an
d
f
ir
e
r
is
k
,
a
n
d
m
u
s
t
also
p
ay
atten
tio
n
to
th
e
h
u
m
a
n
f
ac
to
r
wo
r
k
in
g
in
th
e
h
o
s
p
ital.
T
h
e
h
u
m
a
n
f
ac
to
r
o
f
co
n
ce
r
n
is
h
ea
lth
ca
r
e
p
er
s
o
n
n
el
wh
o
d
ir
ec
tly
in
ter
ac
t
with
p
atien
ts
.
Hea
lth
ca
r
e
p
er
s
o
n
n
el
p
lay
a
v
er
y
im
p
o
r
ta
n
t
r
o
le
if
th
ey
ca
n
m
in
im
ize
co
m
p
licatio
n
s
in
p
atien
t
ca
r
e,
f
o
r
ex
a
m
p
le,
p
o
s
to
p
er
ativ
e
b
l
ee
d
in
g
o
r
f
etal
d
is
tr
ess
d
u
r
in
g
lab
o
r
.
Seco
n
d
ar
y
in
f
ec
ti
o
n
s
d
u
r
in
g
tr
ea
t
m
en
t
ar
e
h
az
ar
d
s
o
r
co
m
p
licatio
n
s
also
ass
o
ciate
d
with
p
atien
t
ca
r
e.
T
h
is
co
m
p
licatio
n
ca
n
n
o
t
o
n
ly
b
e
p
r
ev
e
n
ted
b
y
g
iv
in
g
ad
v
ice
an
d
war
n
i
n
g
s
t
o
h
ea
lth
ca
r
e
p
er
s
o
n
n
el
to
b
e
m
o
r
e
ca
r
ef
u
l.
Ho
wev
er
,
it
is
n
ec
ess
ar
y
to
b
u
ild
a
co
n
ce
p
t
t
h
at
is
h
o
lis
tically
ex
p
ec
ted
t
o
p
r
ev
en
t
m
ed
ical
er
r
o
r
s
f
r
o
m
o
cc
u
r
r
in
g
,
wh
ich
is
f
o
cu
s
ed
o
n
th
e
h
ea
lth
ca
r
e
p
er
s
o
n
n
el
[
9
]
.
Ma
n
ag
in
g
h
ea
lth
ca
r
e
p
er
s
o
n
n
el
in
h
o
s
p
itals
is
n
o
t
ea
s
y
b
ec
au
s
e
h
ea
lth
ca
r
e
p
er
s
o
n
n
el
h
av
e
d
if
f
er
en
t
b
ac
k
g
r
o
u
n
d
s
,
in
clu
d
in
g
d
if
f
er
en
ce
s
in
b
ac
k
g
r
o
u
n
d
,
ex
p
er
ie
n
ce
,
an
d
s
k
ills
.
I
n
ad
d
itio
n
,
th
er
e
ar
e
in
tr
in
s
ic
f
ac
to
r
s
s
u
ch
as
attitu
d
e,
b
eli
ef
s
,
an
d
p
er
s
o
n
ality
th
at
ca
n
in
f
lu
en
ce
b
e
h
av
io
r
.
T
h
er
ef
o
r
e,
a
m
o
r
e
h
u
m
an
e
ap
p
r
o
ac
h
is
n
ee
d
ed
to
m
o
tiv
ate
h
ea
lth
p
er
s
o
n
n
el
s
o
th
ey
ca
n
m
ak
e
p
atien
t
s
af
ety
a
wo
r
k
cu
ltu
r
e.
On
e
r
elativ
ely
n
ew
ap
p
r
o
ac
h
u
s
ed
i
n
h
o
s
p
ital o
r
g
an
izatio
n
s
is
p
s
y
ch
o
lo
g
ical
em
p
o
wer
m
en
t.
E
m
p
o
wer
m
e
n
t
is
d
e
f
in
ed
as
t
h
e
ab
ilit
y
o
f
an
in
d
i
v
id
u
al
to
b
en
e
f
it
f
r
o
m
th
e
r
eso
u
r
ce
s
a
v
ailab
le
to
ac
h
iev
e
g
o
als
an
d
to
m
ak
e
d
e
cisi
o
n
s
in
d
ep
en
d
en
tly
[
7
]
.
Ps
y
ch
o
lo
g
ical
em
p
o
wer
m
e
n
t,
th
e
p
er
ce
p
tio
n
o
f
th
e
d
eg
r
ee
o
f
em
p
o
wer
m
e
n
t
at
wo
r
k
,
is
a
m
o
tiv
atio
n
al
co
n
s
tr
u
ct
m
an
if
ested
in
f
o
u
r
co
g
n
itio
n
s
:
m
ea
n
in
g
,
co
m
p
eten
ce
,
s
elf
-
d
eter
m
in
atio
n
,
an
d
im
p
ac
t
[
1
0
]
,
[
1
1
]
.
Me
a
n
in
g
lea
d
s
to
a
n
i
n
d
iv
id
u
al'
s
i
m
p
o
r
tan
ce
in
h
is
o
r
h
er
wo
r
k
r
o
le.
C
o
m
p
eten
ce
r
ef
er
s
to
s
elf
-
ef
f
icac
y
,
th
e
e
x
ten
t
to
wh
ich
an
in
d
iv
id
u
al
b
eliev
es
th
ey
ca
n
u
n
d
er
tak
e
th
eir
wo
r
k
r
o
le
s
u
cc
ess
f
u
lly
.
I
m
p
ac
t
r
ef
e
r
s
to
th
e
e
x
ten
t
to
wh
ich
a
n
in
d
iv
id
u
al
p
er
ce
iv
es
th
at
h
e
o
r
s
h
e
h
as
s
o
m
e
im
p
ac
t
in
th
eir
im
m
ed
iate
wo
r
k
en
v
ir
o
n
m
en
t.
Self
-
d
eter
m
in
atio
n
r
ef
er
s
to
s
elf
-
d
ir
ec
tin
g
o
n
e'
s
wo
r
k
[
8
]
.
B
ased
o
n
th
e
e
x
p
lan
atio
n
o
f
th
ese
d
i
m
en
s
io
n
s
,
s
tu
d
ies
r
elate
d
to
p
s
y
ch
o
lo
g
ical
e
m
p
o
wer
m
en
t
m
u
s
t
b
e
ca
r
r
ied
o
u
t u
s
in
g
m
u
ltid
im
e
n
s
io
n
al
m
eth
o
d
s
.
Ps
y
ch
o
lo
g
ical
em
p
o
wer
m
e
n
t
o
f
h
ea
lth
wo
r
k
e
r
s
is
an
ef
f
icien
t
ap
p
r
o
ac
h
an
d
is
r
ar
ely
d
i
s
cu
s
s
ed
in
cu
r
r
en
t
s
tu
d
ies,
esp
ec
ially
c
o
n
ce
r
n
in
g
it
as
a
f
ac
to
r
th
at
ca
n
in
f
lu
e
n
ce
p
atien
t
s
af
ety
cu
lt
u
r
e
[
8
]
,
[
1
2
]
.
Ma
n
y
s
tu
d
ies
o
n
p
s
y
ch
o
lo
g
y
in
th
e
n
o
n
-
h
ea
lth
s
ec
to
r
h
av
e
d
is
cu
s
s
ed
its
b
en
ef
its
,
wh
ile
s
tu
d
ies
an
d
im
p
lem
en
tatio
n
o
f
p
s
y
c
h
o
lo
g
ical
e
m
p
o
wer
m
e
n
t
in
th
e
h
ea
lth
s
ec
to
r
s
till
n
ee
d
to
b
e
co
m
p
leted
[
1
0
]
.
E
v
e
n
th
o
u
g
h
th
is
m
eth
o
d
is
an
ef
f
ec
tiv
e
an
d
ef
f
icien
t
ap
p
r
o
ac
h
to
in
f
lu
en
cin
g
th
e
q
u
ality
o
f
s
er
v
ice
in
h
o
s
p
itals
b
y
in
cr
ea
s
in
g
awa
r
en
ess
ab
o
u
t
p
atien
t
s
af
et
y
cu
ltu
r
e
a
n
d
im
p
r
o
v
i
n
g
p
atie
n
t
o
u
tco
m
es
[
1
3
]
.
T
h
er
e
f
o
r
e,
it
is
im
p
o
r
tan
t
to
s
ee
h
o
w
p
s
y
ch
o
lo
g
ical
em
p
o
wer
m
en
t
(
PE
)
ca
n
r
elate
to
p
a
tien
t
s
af
ety
cu
ltu
r
e
(
PSC
)
a
n
d
im
p
ac
t
p
atien
t
o
u
tco
m
es.
Un
f
o
r
tu
n
ately
,
th
e
s
tu
d
y
o
f
th
is
co
n
ce
p
t is st
ill u
n
d
er
d
ev
elo
p
ed
a
n
d
n
ee
d
s
to
b
e
r
ein
f
o
r
ce
d
[
1
4
]
.
Sev
er
al
s
tu
d
ies
o
n
p
atien
t
s
af
ety
cu
ltu
r
e
h
av
e
b
ee
n
co
n
d
u
c
ted
in
g
o
v
er
n
m
en
t
a
n
d
p
r
iv
at
e
h
o
s
p
itals
[
1
5
]
.
T
h
e
r
esu
lts
s
h
o
w
th
at
co
m
p
ar
in
g
s
u
r
v
ey
r
esu
lts
r
eg
ar
d
in
g
p
atien
t
s
af
ety
cu
ltu
r
e
b
eh
av
io
r
am
o
n
g
h
ea
lth
wo
r
k
er
s
in
th
ese
two
ty
p
es
o
f
h
o
s
p
itals
is
h
ig
h
er
in
p
u
b
lic
h
o
s
p
itals
th
an
in
p
r
iv
ate
h
o
s
p
ita
ls
[
1
6
]
.
T
h
is
ca
n
b
e
id
en
tifie
d
b
ec
au
s
e
th
e
wo
r
k
lo
ad
is
b
ig
g
er
in
p
r
iv
ate
h
o
s
p
itals
[
1
7
]
,
[
1
8
]
.
A
b
lam
e
cu
ltu
r
e
also
co
n
tr
ib
u
tes
to
lo
wer
in
g
th
e
in
ten
tio
n
to
r
e
p
o
r
t
p
atien
t
s
af
ety
-
r
elate
d
ev
en
t
s
.
Pre
v
io
u
s
s
tu
d
ies
s
u
g
g
ested
th
at
p
r
iv
ate
h
o
s
p
itals
s
h
o
u
ld
also
p
ay
m
o
r
e
atten
tio
n
to
p
atien
t
s
af
ety
cu
ltu
r
e
an
d
f
o
cu
s
th
eir
in
v
estme
n
t
o
n
i
n
cr
ea
s
in
g
PS
C
[
1
6
]
,
[
1
9
]
.
Acc
o
r
d
in
g
l
y
,
s
tu
d
ies
o
n
PE
an
d
PS
C
in
p
r
iv
ate
h
o
s
p
itals
s
t
ill
n
ee
d
to
b
e
ca
r
r
ied
o
u
t
an
d
ca
n
co
n
tr
ib
u
te
to
im
p
r
o
v
in
g
p
atien
t o
u
tco
m
es.
T
h
is
s
tu
d
y
'
s
p
u
r
p
o
s
e
to
ev
alu
ate
th
e
co
n
ce
p
t
o
f
p
o
s
itiv
e
r
elatio
n
f
r
o
m
t
h
e
d
im
en
s
io
n
s
o
f
p
atien
t
s
af
ety
cu
ltu
r
e
is
s
u
p
p
o
r
ted
b
y
th
e
d
ev
elo
p
m
en
t
o
f
p
s
y
c
h
o
lo
g
ical
em
p
o
we
r
m
en
t
p
r
o
v
id
ed
in
h
ea
lth
ca
r
e
f
ac
ilit
ies.
T
h
e
ex
p
ec
ted
r
esu
lt
o
f
th
is
m
ed
iatin
g
p
atien
t
s
af
ety
cu
ltu
r
e
r
o
le
is
p
o
s
itiv
ely
r
elate
d
to
p
s
y
ch
o
lo
g
ical
em
p
o
wer
m
e
n
t
an
d
p
atien
t
o
u
tco
m
es
[
2
0
]
.
T
h
is
s
tu
d
y
ca
n
co
n
tr
ib
u
te
b
y
id
en
tif
y
in
g
th
e
m
ed
iatin
g
r
o
le
o
f
PS
C
in
p
r
iv
ate
h
o
s
p
itals
f
r
o
m
a
h
ea
lth
ca
r
e
p
er
s
o
n
n
el
p
s
y
ch
o
lo
g
ical
ap
p
r
o
ac
h
th
at
im
p
r
o
v
es
th
e
q
u
ality
o
f
ca
r
e
f
o
r
p
atien
ts
[
1
]
,
[
2
1
]
.
2.
M
E
T
H
O
D
2
.
1
.
Study
des
ig
n,
pa
rt
icipa
nts,
a
nd
et
hics
a
pp
ro
v
a
l
T
h
e
d
a
t
a
f
o
r
t
h
i
s
c
r
o
s
s
-
s
e
c
t
i
o
n
al
s
t
u
d
y
w
as
o
b
t
a
i
n
e
d
o
n
l
i
n
e
a
m
o
n
g
t
h
e
h
e
a
l
t
h
c
a
r
e
p
e
r
s
o
n
n
e
l i
n
a
p
r
i
v
a
te
h
o
s
p
i
t
a
l
i
n
T
a
n
g
e
r
a
n
g
t
h
a
t
h
a
s
a
l
r
e
a
d
y
o
p
e
r
a
t
e
d
f
o
r
3
0
y
e
a
r
s
,
w
i
t
h
a
b
o
v
e
2
0
0
b
e
d
s
c
a
p
a
c
it
y
,
w
h
i
c
h
h
a
s
al
r
e
a
d
y
b
e
e
n
a
c
c
r
e
d
i
t
e
d
b
y
J
o
i
n
t
C
o
m
m
i
s
s
i
o
n
I
n
t
e
r
n
a
t
i
o
n
a
l
(
J
C
I
)
.
T
h
i
s
h
o
s
p
i
t
al
i
s
t
h
e
f
i
r
s
t
p
r
i
v
a
t
e
h
o
s
p
i
t
a
l
i
n
T
a
n
g
e
r
a
n
g
a
n
d
i
s
o
n
e
o
f
t
h
e
p
r
i
m
a
r
y
h
e
a
lth
c
a
r
e
r
e
f
e
r
r
a
l
h
o
s
p
i
t
al
s
w
it
h
a
to
t
a
l
o
f
a
p
p
r
o
x
i
m
a
te
l
y
2
4
0
,
0
0
0
p
a
t
i
e
n
ts
t
r
e
at
e
d
p
e
r
y
e
a
r
.
T
h
e
r
e
s
ea
r
c
h
p
o
p
u
l
a
t
i
o
n
i
s
a
l
l
h
e
a
l
t
h
c
a
r
e
p
e
r
s
o
n
n
e
l
wh
o
h
a
v
e
w
o
r
k
e
d
i
n
t
h
e
h
o
s
p
i
ta
l
f
o
r
t
h
r
e
e
y
e
a
r
s
o
r
m
o
r
e
.
T
h
e
r
e
s
e
a
r
c
h
s
a
m
p
l
e
i
n
t
h
i
s
s
t
u
d
y
u
s
e
d
t
h
e
ce
n
s
u
s
s
am
p
l
i
n
g
m
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Evaluation Warning : The document was created with Spire.PDF for Python.
I
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2
2
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I
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b
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Dec
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20
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:
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Data
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5
1
q
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co
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is
tin
g
o
f
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ilter
q
u
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s
[
2
2
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an
d
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ee
s
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ized
,
v
alid
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a
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eliab
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L
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s
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[
1
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]
,
ii
)
s
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ety
clim
ate
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u
esti
o
n
n
air
e
[
2
3
]
,
an
d
iii
)
p
atien
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o
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tco
m
e
[
2
4
]
.
T
h
e
p
s
y
ch
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ical
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1
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th
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,
ii
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th
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,
iii
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s
elf
-
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th
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an
d
iv
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th
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T
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iii
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v
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g
co
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d
itio
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(
f
o
u
r
item
s
)
,
an
d
t
h
e
p
atien
t o
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tco
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e
was a
s
s
ess
ed
u
s
in
g
s
ix
q
u
esti
o
n
s
ad
ap
ted
f
r
o
m
th
e
p
r
ev
io
u
s
s
tu
d
y
[
2
3
]
.
Ps
y
ch
o
lo
g
ical
em
p
o
we
r
m
en
t
is
a
h
u
m
an
ca
p
ital
a
p
p
r
o
ac
h
wid
ely
u
s
ed
in
o
r
g
an
izatio
n
s
[
2
5
]
,
[
2
6
]
.
Ma
n
y
s
tu
d
ies
r
eg
a
r
d
in
g
th
e
r
esu
lts
o
f
th
e
r
elatio
n
s
h
ip
b
et
wee
n
PE
an
d
p
atien
t
o
u
tco
m
e
(
PO
)
h
a
v
e
b
ee
n
ca
r
r
ied
o
u
t
.
Ho
wev
er
,
p
s
y
ch
o
lo
g
ical
em
p
o
wer
m
e
n
t
co
m
m
o
n
ly
ac
ts
as
a
m
ed
iatin
g
v
a
r
iab
le
[
1
2
]
.
T
h
er
ef
o
r
e,
th
is
s
tu
d
y
attem
p
ts
to
d
ep
lo
y
p
s
y
ch
o
lo
g
ical
em
p
o
wer
m
e
n
t
as
an
in
d
ep
en
d
en
t
v
ar
iab
le.
I
n
th
is
s
tu
d
y
,
p
s
y
ch
o
lo
g
ical
em
p
o
we
r
m
en
t
was
an
aly
ze
d
u
s
in
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d
im
en
s
io
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al
an
al
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is
in
p
ar
tial
least
s
q
u
ar
es
s
tr
u
ctu
r
al
eq
u
atio
n
m
o
d
elin
g
(
PLS
-
SEM
)
an
d
p
r
e
d
icted
f
u
r
th
e
r
th
e
r
o
le
o
f
th
is
in
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ep
en
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en
t
v
ar
ia
b
le
an
d
in
d
icato
r
to
s
u
p
p
o
r
t
PS
C
[
1
2
]
.
W
ith
in
th
e
h
ea
lth
ca
r
e
s
ec
to
r
,
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m
e
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ies
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av
e
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o
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n
d
p
s
y
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g
ical
em
p
o
wer
m
en
t
to
b
e
an
im
p
o
r
ta
n
t a
n
tece
d
e
n
t o
f
th
e
q
u
ality
o
f
p
atien
t c
ar
e
s
af
ety
[
2
7
]
,
[
2
8
]
.
Patien
t
s
af
ety
cu
ltu
r
e
is
d
ef
in
ed
as
“
th
e
v
alu
es
s
h
ar
ed
am
o
n
g
o
r
g
an
izatio
n
m
em
b
er
s
ab
o
u
t
wh
at
is
im
p
o
r
tan
t,
t
h
eir
b
elief
s
ab
o
u
t
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w
th
in
g
s
o
p
e
r
ate
in
th
e
o
r
g
an
izatio
n
,
a
n
d
th
e
in
ter
ac
tio
n
o
f
t
h
ese
with
th
e
wo
r
k
in
g
u
n
it
an
d
o
r
g
an
izatio
n
al
s
tr
u
ctu
r
es
an
d
s
y
s
tem
s
,
wh
ich
to
g
eth
er
p
r
o
d
u
ce
b
eh
a
v
io
r
al
n
o
r
m
s
in
th
e
h
ea
lth
ca
r
e
th
at
p
r
o
m
o
tes
s
af
ety
”
[
2
9
]
.
Patien
t
s
af
ety
s
h
o
u
ld
b
e
a
to
p
s
tr
ateg
ic
p
r
io
r
ity
f
o
r
h
ea
lth
ca
r
e
o
r
g
an
izatio
n
s
an
d
th
eir
lead
er
s
.
T
h
er
e
s
h
o
u
ld
b
e
a
b
lam
e
-
f
r
ee
s
y
s
tem
f
o
r
id
en
tify
in
g
th
r
e
ats
to
p
atien
t
s
af
ety
,
s
h
ar
in
g
in
f
o
r
m
atio
n
,
an
d
lear
n
in
g
f
r
o
m
ev
en
ts
.
I
n
ad
d
itio
n
,
th
er
e
s
h
o
u
ld
b
e
a
c
o
llab
o
r
at
iv
e
en
v
ir
o
n
m
en
t
s
o
th
at
all
h
ea
lth
p
er
s
o
n
n
el
in
t
h
e
h
ea
lth
ca
r
e
o
r
g
an
izatio
n
ca
n
s
h
ar
e
an
d
ex
ch
a
n
g
e
in
f
o
r
m
atio
n
ab
o
u
t
p
atien
t
s
af
ety
[
3
0
]
.
T
h
e
r
o
le
o
f
PS
C
as
a
m
ed
iato
r
in
PE
a
n
d
PO
ca
n
b
e
d
e
p
icted
in
a
co
n
ce
p
tu
al
f
r
am
ewo
r
k
as
in
Fig
u
r
e
1
.
Fu
r
th
er
,
th
e
f
o
u
r
d
im
en
s
io
n
s
o
f
PE
an
d
th
e
f
iv
e
d
im
en
s
io
n
s
o
f
PS
C
ar
e
als
o
d
escr
ib
ed
in
th
e
co
n
ce
p
tu
al
f
r
am
ewo
r
k
.
T
h
e
s
t
u
d
y
o
f
h
ea
lth
ca
r
e
p
er
s
o
n
n
el
is
also
r
elate
d
to
th
e
len
g
th
o
f
s
er
v
ice.
So
th
at
th
e
len
g
th
o
f
s
er
v
ice
(
L
OS)
ca
n
b
e
co
n
s
id
er
e
d
a
m
o
d
e
r
ato
r
o
f
th
e
r
elatio
n
s
h
ip
b
etwe
en
v
ar
iab
les
in
th
e
f
r
am
ewo
r
k
.
T
h
er
e
f
o
r
e
,
L
OS is in
clu
d
ed
as a
m
o
d
er
atin
g
v
ar
i
ab
le
in
th
is
co
n
ce
p
t
u
al
f
r
am
ew
o
r
k
[
3
1
]
.
Fig
u
r
e
1
.
C
o
n
ce
p
tu
al
f
r
a
m
ewo
r
k
D
a
t
a
a
n
a
l
y
s
is
u
s
i
n
g
t
h
e
l
a
t
es
t
a
n
a
l
y
s
is
m
e
t
h
o
d
i
n
P
L
S
-
S
E
M
,
n
a
m
e
l
y
t
h
e
d
i
s
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o
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o
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d
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r
a
d
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t
i
o
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l
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h
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d
,
r
e
p
e
a
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d
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a
t
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s
.
T
h
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a
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H
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d
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.
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t
r
u
c
t
u
r
a
l
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q
u
a
t
i
o
n
m
o
d
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l
in
g
(
S
E
M
)
a
n
a
l
y
s
i
s
te
s
ts
p
r
i
o
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h
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p
o
t
h
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e
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w
ee
n
l
a
t
e
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t
v
a
r
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a
b
le
c
o
r
r
e
l
a
t
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a
n
d
c
o
v
a
r
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a
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m
a
t
r
i
x
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t
o
d
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m
i
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a
n
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a
n
a
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e
r
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l
a
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p
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w
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t
h
e
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r
e
t
ic
a
l
c
o
n
c
e
p
t
s
[
3
2
]
,
[
33]
.
T
h
e
co
n
ce
p
tu
al
f
r
am
ewo
r
k
c
o
n
s
is
ts
o
f
lo
w
-
o
r
d
er
c
o
n
s
tr
u
ct
(
L
OC
)
an
d
h
ig
h
-
o
r
d
e
r
co
n
s
tr
u
ct
(
HOC)
v
ar
iab
les
to
ex
ten
d
th
e
s
tan
d
ar
d
c
o
n
s
tr
u
c
t
co
n
ce
p
tu
aliza
tio
n
o
f
t
h
e
f
r
a
m
ewo
r
k
in
s
tead
o
f
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J
Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
P
a
tien
t sa
fety
cu
ltu
r
e
a
s
a
me
d
ia
to
r
b
etw
ee
n
h
ea
lth
c
a
r
e
…
(
E
ld
a
a
P
r
is
ca
R
efia
n
ti S
u
ta
n
to
)
1915
r
ely
in
g
o
n
a
s
in
g
le
lay
er
o
f
ab
s
tr
ac
tio
n
.
Hig
h
-
o
r
d
er
co
n
s
tr
u
ct
esti
m
ated
b
y
u
s
in
g
th
e
d
is
jo
in
t
two
-
s
tag
e
ap
p
r
o
ac
h
[
3
4
]
.
T
h
e
laten
t v
ar
i
ab
le
(
L
V)
s
co
r
es f
r
o
m
th
e
f
ir
s
t
s
tag
e
ar
e
u
s
ed
as in
p
u
t f
o
r
th
e
s
ec
o
n
d
s
tag
e
HOC
in
d
icato
r
s
,
wh
ile
all
th
e
o
th
e
r
(
n
o
n
h
ier
ar
c
h
ical)
co
n
s
tr
u
cts
,
th
e
p
atien
t
o
u
tc
o
m
e,
ar
e
m
ea
s
u
r
ed
with
th
eir
o
r
ig
in
al
in
d
icato
r
s
.
All
th
e
co
n
s
tr
u
ct
m
ea
s
u
r
es
in
th
e
s
ec
o
n
d
s
tag
e,
n
o
t
o
n
ly
th
o
s
e
o
f
th
e
HOC,
th
en
th
e
m
o
d
el’
s
p
r
ed
ictiv
e
p
o
wer
o
n
an
in
d
icato
r
lev
el
was
an
aly
z
ed
b
y
ca
lcu
latin
g
th
e
cr
o
s
s
-
v
alid
ated
p
r
ed
ictiv
e
ab
ilit
y
test
(
C
VPAT
)
p
r
o
ce
d
u
r
e
[
3
5
]
,
[
3
6
]
.
3.
RE
SU
L
T
S AN
D
D
I
SCU
SS
I
O
N
3
.
1
.
Resul
t
3
.
1
.
1
.
Cha
ra
ct
er
is
t
ics o
f
re
s
po
nd
ent
s
T
h
er
e
wer
e
o
n
e
h
u
n
d
r
e
d
an
d
f
if
ty
h
ea
lth
ca
r
e
p
er
s
o
n
n
el
j
o
in
ed
th
is
s
tu
d
y
an
d
t
h
e
d
em
o
g
r
ap
h
ic
d
ata
ar
e
p
r
esen
ted
in
T
ab
le
1
.
Me
d
ical
p
er
s
o
n
n
el
in
th
is
s
tu
d
y
wer
e
d
o
m
in
ated
b
y
wo
m
e
n
(
7
9
%)
co
m
p
ar
e
d
to
m
en
,
a
n
d
7
7
%
o
f
r
esp
o
n
d
en
ts
wer
e
m
ar
r
ie
d
.
B
ased
o
n
th
e
ag
e
g
r
o
u
p
,
th
e
m
ajo
r
ity
o
f
m
ed
ical
p
er
s
o
n
n
el
ag
ed
35
-
4
5
y
ea
r
s
wer
e
f
o
u
n
d
in
th
is
s
tu
d
y
(
3
9
%).
As
m
u
ch
as
6
1
%
o
f
r
esp
o
n
d
en
ts
h
av
e
th
e
last
d
ip
lo
m
a
ed
u
ca
tio
n
an
d
m
o
s
t
o
f
th
e
wo
r
k
p
o
s
itio
n
s
in
th
is
s
tu
d
y
ar
e
n
u
r
s
es
(
5
9
%).
As
m
an
y
as
5
9
%
o
f
r
esp
o
n
d
en
ts
in
th
is
s
tu
d
y
h
ad
wo
r
k
ed
as
h
ea
lth
wo
r
k
er
s
f
o
r
1
0
y
ea
r
s
o
r
m
o
r
e,
with
th
e
h
ig
h
est
p
r
o
p
o
r
tio
n
o
f
w
o
r
k
i
n
g
d
u
r
atio
n
(
8
1
%),
n
am
ely
>4
0
h
o
u
r
s
p
er
wee
k
.
As
m
an
y
as
8
8
%
o
f
r
esp
o
n
d
e
n
ts
in
th
is
s
tu
d
y
m
ad
e
d
ir
ec
t
c
o
n
tact
with
p
atien
ts
.
Mo
s
t o
f
th
e
em
p
l
o
y
m
en
t statu
s
o
f
th
e
r
esp
o
n
d
en
ts
in
th
is
s
tu
d
y
wer
e
also
em
p
lo
y
ee
s
with
p
er
m
an
en
t statu
s
.
T
ab
le
1
.
R
esp
o
n
d
e
n
ts
p
r
o
f
ile
C
a
t
e
g
o
r
y
D
e
scri
p
t
i
o
n
S
a
mp
l
e
(
n
)
P
e
r
c
e
n
t
a
g
e
G
e
n
d
e
r
F
e
mal
e
1
1
9
7
9
%
M
a
l
e
31
2
1
%
M
a
r
i
t
a
l
s
t
a
t
u
s
M
a
r
r
i
e
d
1
1
6
7
7
%
S
i
n
g
l
e
34
2
3
%
A
g
e
(
y
e
a
r
s o
l
d
)
18
–
<
2
5
18
1
2
%
25
–
<
3
5
50
3
3
%
35
–
<
4
5
58
3
9
%
45
–
55
21
1
4
%
>
5
5
3
2%
Ed
u
c
a
t
i
o
n
B
a
c
h
e
l
o
r
19
1
3
%
D
i
p
l
o
m
a
92
6
1
%
P
o
st
g
r
a
d
u
a
t
e
3
2%
P
r
o
f
e
ssi
o
n
a
l
(
d
o
c
t
o
r
,
r
a
d
i
o
g
r
a
p
h
e
r
,
p
h
y
si
o
t
h
e
r
a
p
i
st
,
a
n
d
nu
r
s
e
)
36
2
4
%
W
o
r
k
i
n
g
p
o
si
t
i
o
n
B
i
o
me
d
i
c
a
l
e
n
g
i
n
e
e
r
i
n
g
st
a
f
f
(
r
a
d
i
o
g
r
a
p
h
e
r
s,
e
l
e
c
t
r
o
m
e
d
i
c
a
l
,
me
d
i
c
a
l
l
a
b
o
r
a
t
o
r
i
e
s
,
m
e
d
i
c
a
l
p
h
y
s
i
c
i
st
s
,
r
a
d
i
o
t
h
e
r
a
p
i
st
s)
21
1
4
%
M
e
d
i
c
a
l
p
e
r
so
n
n
e
l
(
g
e
n
e
r
a
l
p
r
a
c
t
i
t
i
o
n
e
r
,
d
e
n
t
i
st
,
a
n
d
s
p
e
c
i
a
l
i
s
t
)
12
8%
M
e
d
i
c
a
l
t
e
c
h
n
i
c
i
a
n
s (m
e
d
i
c
a
l
r
e
c
o
r
d
s
a
n
d
h
e
a
l
t
h
i
n
f
o
r
ma
t
i
o
n
,
c
a
r
d
i
o
v
a
sc
u
l
a
r
t
e
c
h
n
i
c
i
a
n
,
a
n
e
st
h
e
s
i
o
l
o
g
i
st
a
ss
i
st
a
n
t
)
8
5%
N
u
r
se
88
5
9
%
N
u
t
r
i
t
i
o
n
i
s
t
a
n
d
d
i
e
t
i
t
i
a
n
7
5%
P
h
a
r
ma
c
e
u
t
i
c
a
l
s
t
a
f
f
(
p
h
a
r
ma
c
i
s
t
s a
n
d
p
h
a
r
ma
c
e
u
t
i
c
a
l
t
e
c
h
n
i
c
a
l
p
e
r
s
o
n
n
e
l
)
3
2%
R
e
h
a
b
i
l
i
t
a
t
i
o
n
p
h
y
si
c
i
s
t
,
t
h
e
r
a
p
y
p
e
r
s
o
n
n
e
l
(
p
h
y
s
i
o
t
h
e
r
a
p
i
s
t
,
o
c
c
u
p
a
t
i
o
n
a
l
t
h
e
r
a
p
i
st
,
s
p
e
e
c
h
t
h
e
r
a
p
i
st
)
11
7%
Le
n
g
t
h
o
f
s
e
r
v
i
c
e
(
y
e
a
r
)
3
–
5
31
2
1
%
5
–
<
1
0
30
2
0
%
≥
1
0
89
5
9
%
W
o
r
k
i
n
g
h
o
u
r
s
(
p
e
r
w
e
e
k
)
>
4
0
h
o
u
r
s
1
2
1
8
1
%
≤
4
0
h
o
u
r
s
29
1
9
%
D
i
r
e
c
t
c
o
n
t
a
c
t
w
i
t
h
p
a
t
i
e
n
t
No
18
1
2
%
Y
e
s
1
3
2
8
8
%
Emp
l
o
y
me
n
t
s
t
a
t
u
s
C
o
n
t
r
a
c
t
13
9%
P
e
r
man
e
n
t
1
3
7
9
1
%
3
.
1
.
2
.
M
ea
s
urem
ent
m
o
del
T
o
estab
lis
h
th
e
r
eliab
ilit
y
in
d
icato
r
,
th
e
o
u
ter
lo
a
d
in
g
wa
s
m
ea
s
u
r
ed
,
an
d
o
n
e
i
n
d
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r
(
W
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elim
in
ated
th
at
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n
o
t
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d
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e
r
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estab
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h
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t v
alid
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.
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8
8
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6
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d
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C
P
M
N
S
C
L
S
EL
TC
L
W
C
N
C
O
M
I
M
P
0
.
6
0
3
JS
T
0
.
5
4
6
0
.
6
0
2
M
EA
0
.
6
9
4
0
.
5
3
4
0
.
5
2
8
P
O
C
0
.
4
7
4
0
.
3
9
3
0
.
5
1
8
0
.
3
8
3
P
M
N
0
.
5
6
7
0
.
6
0
4
0
.
7
1
1
0
.
5
1
1
0
.
4
9
7
S
C
L
0
.
4
7
0
0
.
5
7
6
0
.
7
0
6
0
.
4
7
7
0
.
5
5
9
0
.
6
4
4
S
EL
0
.
4
3
5
0
.
7
2
9
0
.
4
2
1
0
.
2
9
9
0
.
4
0
5
0
.
4
3
8
0
.
3
1
2
TC
L
0
.
5
4
7
0
.
7
0
4
0
.
7
5
7
0
.
5
5
7
0
.
6
3
6
0
.
7
2
0
0
.
7
2
6
0
.
4
6
0
W
C
N
0
.
5
1
6
0
.
5
3
6
0
.
6
5
9
0
.
4
4
2
0
.
6
9
2
0
.
6
3
3
0
.
6
1
1
0
.
4
1
6
0
.
7
0
8
M
EA
:
M
e
a
n
i
n
g
,
C
O
M
:
C
o
mp
e
t
e
n
c
e
,
S
EL:
S
e
l
f
-
d
e
t
e
r
mi
n
a
t
i
o
n
,
I
M
P
:
I
mp
a
c
t
,
T
C
L
:
T
e
a
mw
o
r
k
c
l
i
ma
t
e
,
S
C
L:
S
a
f
e
t
y
c
l
i
m
a
t
e
,
JS
T:
J
o
b
sa
t
i
sf
a
c
t
i
o
n
,
P
M
N
:
P
e
r
c
e
p
t
i
o
n
o
f
ma
n
a
g
e
me
n
t
,
W
C
N
:
W
o
r
k
i
n
g
c
o
n
d
i
t
i
o
n
,
P
O
C
:
P
a
t
i
e
n
t
o
u
t
c
o
me
I
n
ac
co
r
d
an
ce
with
th
e
two
-
s
tag
e
m
eth
o
d
,
it
is
also
n
ec
ess
ar
y
to
r
e
p
o
r
t
th
e
r
eliab
ilit
y
a
n
d
v
alid
ity
an
aly
s
is
o
f
th
e
HOC
an
d
L
O
C
.
T
h
e
r
esu
lts
o
f
th
e
HOC
as
s
ess
m
en
t
ca
n
b
e
ass
ess
ed
in
T
ab
le
4
,
wh
e
r
e
it
ca
n
b
e
ascer
tain
ed
th
at
th
e
HOC
co
n
s
tr
u
ct
h
as
s
atis
f
ac
to
r
y
r
e
liab
ilit
y
an
d
v
alid
ity
(
AVE
>0
.
5
,
C
A>
0
.
6
0
)
.
T
h
e
v
alid
r
esu
lt
o
f
th
e
f
ir
s
t
s
tag
e
o
f
HT
/MT
is
ca
lcu
lated
.
T
h
e
s
e
co
n
d
s
tag
e
o
f
d
is
cr
im
in
an
t
v
alid
ity
with
HT
/MT
an
aly
s
is
was
ca
lcu
lated
u
s
in
g
th
e
laten
t
v
ar
iab
le
s
co
r
e
o
f
PE,
PS
C
,
an
d
PO.
T
h
e
ca
lcu
latio
n
r
esu
lts
o
f
s
ec
o
n
d
s
tag
e
d
is
cr
im
in
an
t
v
alid
ity
wi
th
HT
/MT
r
atio
ar
e
p
r
esen
te
d
in
T
a
b
le
5
,
w
h
er
e
all
in
d
icat
o
r
s
ar
e
s
p
ec
if
ied
t
o
m
ea
s
u
r
e
th
eir
r
esp
ec
tiv
e
c
o
n
s
tr
u
ct,
it
was
co
n
clu
d
e
d
th
at
al
l
th
e
in
d
icato
r
s
in
th
is
r
esear
c
h
m
o
d
el
h
ad
b
ee
n
well
d
is
cr
im
in
ated
ag
ain
s
t,
s
o
th
ey
co
u
l
d
m
ea
s
u
r
e
th
eir
r
esp
e
ctiv
e
co
n
s
tr
u
cts.
T
ab
le
4
.
Seco
n
d
s
tag
e
r
eliab
ili
ty
an
d
v
alid
ity
an
aly
s
is
V
a
r
i
a
b
l
e
s (
h
i
g
h
o
r
d
e
r
c
o
n
st
r
u
c
t
s)
CA
CR
AVE
P
a
t
i
e
n
t
o
u
t
c
o
m
e
0
.
8
8
7
0
.
9
1
5
0
.
6
4
6
P
a
t
i
e
n
t
s
a
f
e
t
y
c
u
l
t
u
r
e
0
.
8
9
1
0
.
9
2
0
0
.
6
9
7
P
sy
c
h
o
l
o
g
i
c
a
l
e
mp
o
w
e
r
m
e
n
t
0
.
7
8
7
0
.
8
6
3
0
.
6
1
2
A
V
E:
A
v
e
r
a
g
e
v
a
r
i
a
n
c
e
e
x
t
r
a
c
t
e
d
,
C
A
:
C
r
o
n
b
a
c
h
'
s a
l
p
h
a
,
C
R
:
C
o
m
p
o
si
t
e
r
e
l
i
a
b
i
l
i
t
y
T
ab
le
5
.
Seco
n
d
s
tag
e
d
is
cr
im
in
an
t v
alid
ity
w
ith
HT
/MT
r
ati
o
V
a
r
i
a
b
l
e
s (h
i
g
h
o
r
d
e
r
c
o
n
st
r
u
c
t
s
)
P
a
t
i
e
n
t
o
u
t
c
o
m
e
P
a
t
i
e
n
t
s
a
f
e
t
y
c
u
l
t
u
r
e
P
sy
c
h
o
l
o
g
i
c
a
l
e
mp
o
w
e
r
m
e
n
t
P
a
t
i
e
n
t
o
u
t
c
o
m
e
P
a
t
i
e
n
t
s
a
f
e
t
y
c
u
l
t
u
r
e
0
.
6
8
9
(
C
I
0
.
5
9
8
–
0
.
7
7
2
)
P
sy
c
h
o
l
o
g
i
c
a
l
e
mp
o
w
e
r
m
e
n
t
0
.
5
4
6
0
.
8
2
6
(
C
I
0
.
3
8
1
–
0
.
6
9
6
)
(
C
I
0
.
7
5
0
–
0
.
8
9
5
)
T
h
e
in
n
er
m
o
d
el
an
aly
s
is
is
th
e
s
ec
o
n
d
p
ar
t
an
al
y
s
is
to
ev
alu
ate
th
e
q
u
ality
o
f
th
e
m
o
d
el
in
th
is
r
esear
ch
b
y
p
r
e
d
ictin
g
th
e
r
el
atio
n
b
etwe
en
v
ar
iab
les/
p
ar
a
m
eter
s
in
th
e
in
n
er
m
o
d
el
co
n
s
is
tin
g
o
f
R
-
s
q
u
ar
e
(R
2
)
,
Q
-
s
q
u
ar
e
(
Q
2
)
,
an
d
v
ar
i
an
ce
in
f
latio
n
f
ac
to
r
(
VI
F).
R
2
to
m
ea
s
u
r
e
p
r
ed
ictiv
e
ac
cu
r
ac
y
,
Q
2
to
m
ea
s
u
r
e
p
r
ed
ictiv
e
r
elev
a
n
ce
an
d
th
e
s
ig
n
if
ican
ce
an
d
co
ef
f
icien
t
o
f
th
e
v
ar
iab
le
ar
e
to
d
ec
id
e
wh
e
th
er
th
e
h
y
p
o
th
esis
ca
n
b
e
s
u
p
p
o
r
ted
o
r
n
o
t.
Pre
v
io
u
s
ly
,
co
m
m
o
n
m
et
h
o
d
b
ia
s
ar
is
in
g
f
r
o
m
er
r
o
r
s
o
r
b
iases
in
m
ea
s
u
r
em
en
t
m
eth
o
d
o
l
o
g
y
was e
v
alu
ate
d
u
s
in
g
th
e
in
n
er
VI
F.
T
h
e
im
p
o
r
tan
ce
o
f
co
n
d
u
ctin
g
th
e
i
n
n
er
VI
F
test
is
to
ch
e
ck
m
u
ltico
llin
ea
r
ity
is
s
u
es.
T
h
e
f
in
d
i
n
g
s
s
h
o
wed
all
th
e
co
n
s
tr
u
cts
h
a
d
in
n
er
VI
F
b
elo
w
f
iv
e
as
s
u
g
g
ested
[
3
3
]
,
[
3
7
]
;
th
u
s
,
it
ca
n
b
e
co
n
clu
d
ed
th
at
th
er
e
is
n
o
m
u
ltico
llin
ea
r
ity
is
s
u
e
f
o
u
n
d
i
n
th
is
m
o
d
el.
T
h
e
R
2
v
alu
e
o
f
p
atien
t
s
af
ety
cu
lt
u
r
e
=0
.
5
1
2
,
wh
ic
h
is
ca
teg
o
r
ized
as
m
o
d
er
ate
p
r
ed
ictiv
e
ac
cu
r
ac
y
an
d
p
atien
t
o
u
tco
m
e
h
as
R
2
=0
.
4
0
0
,
w
h
ich
is
ca
teg
o
r
ize
d
as
m
o
d
er
ate
p
r
e
d
ictiv
e
ac
cu
r
ac
y
.
B
lu
e
an
d
g
r
ee
n
b
o
x
es
in
d
icat
e
th
e
d
im
en
s
io
n
s
o
f
th
e
co
n
s
tr
u
ct.
T
h
e
y
ello
w
b
o
x
in
d
icate
s
th
e
d
ep
en
d
en
t
v
a
r
ia
b
le
in
d
icato
r
s
.
All
th
e
Q
2
ar
e
f
o
u
n
d
>0
with
th
e
h
ig
h
est
Q
2
in
team
wo
r
k
clim
ate
(Q
2
=0
.
3
8
9
)
,
wh
ich
was
ca
teg
o
r
ized
as
m
ed
iu
m
p
r
ed
ictiv
e
v
alu
e
(
0
.
2
5
–
0
.
5
0
)
,
s
ee
Fig
u
r
e
2
.
T
h
er
e
f
o
r
e,
it
ca
n
b
e
ex
p
lain
e
d
th
at
co
n
s
tr
u
cts in
th
e
o
u
t
-
of
-
s
am
p
le
m
o
d
el
ap
p
r
o
ac
h
h
a
v
e
s
u
f
f
icien
t c
r
o
s
s
-
v
alid
ated
r
ed
u
n
d
a
n
cy
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
1
3
,
No
.
4
,
Dec
em
b
er
20
24
:
1
91
2
-
1
92
3
1918
Fig
u
r
e
2
.
Stru
ctu
r
al
m
o
d
el
I
n
m
o
d
els
th
at
h
av
e
m
u
ltip
le
p
ath
s
,
it
is
r
ec
o
m
m
en
d
e
d
to
ass
es
s
th
e
p
-
v
alu
e
u
s
in
g
th
e
co
r
r
ec
ted
p
-
v
alu
e,
B
o
n
f
e
r
r
o
n
i.
T
h
e
ca
lcu
lated
p
-
v
alu
e
is
d
iv
id
ed
b
y
t
h
e
o
b
s
er
v
ed
p
ath
,
with
a
r
esu
l
t
o
f
0
.
0
0
7
.
B
ased
o
n
th
e
r
esu
lt
o
f
h
y
p
o
th
esis
test
in
g
with
th
e
b
o
o
ts
tr
ap
p
in
g
f
ea
t
u
r
e
,
s
ee
T
ab
le
6
.
It
was
s
h
o
w
n
t
h
at
th
er
e
wer
e
th
r
ee
s
u
p
p
o
r
ted
h
y
p
o
th
eses
wh
ich
a
r
e
H1
,
H3
,
an
d
H4
(
with
p
<0
.
0
5
,
c
o
r
r
ec
ted
p
-
v
al
u
e<
0
.
0
0
7
,
an
d
n
o
ze
r
o
-
v
alu
e
f
o
u
n
d
b
etwe
en
in
ter
v
al
C
I
5
%
an
d
C
I
9
5
%).
On
th
e
o
th
er
s
i
d
e,
th
e
s
tan
d
ar
d
ized
co
ef
f
icien
t
was
p
o
s
itiv
e
an
d
in
ac
co
r
d
a
n
ce
with
th
e
p
u
r
p
o
s
e
h
y
p
o
t
h
esis
(
d
ir
ec
tio
n
al
h
y
p
o
th
esis
)
.
T
h
ese
f
in
d
in
g
s
s
h
o
w
th
at
PE
h
as
a
s
ig
n
if
ican
tly
p
o
s
itiv
e
r
elatio
n
s
h
ip
with
PS
C
,
an
d
PS
C
h
a
s
a
s
ig
n
if
ican
tly
p
o
s
itiv
e
r
el
atio
n
s
h
ip
with
PO.
Ho
wev
er
,
th
e
r
elatio
n
b
etwe
e
n
PE
an
d
PO
(
H2
)
ca
n
n
o
t
b
e
e
s
tab
lis
h
ed
s
in
ce
th
e
p
-
v
alu
e<
0
.
0
5
an
d
th
e
f
i
n
d
in
g
o
f
ze
r
o
i
n
th
e
r
an
g
e
o
f
co
n
f
i
d
en
ce
in
ter
v
al.
T
h
er
ef
o
r
e,
th
is
s
tu
d
y
d
em
o
n
s
tr
ated
th
at
th
e
m
ed
iatin
g
b
y
PS
C
i
s
f
u
ll m
ed
iatio
n
.
T
ab
le
6
.
Hy
p
o
th
esis
test
r
esu
lts
H
y
p
o
t
h
e
s
i
s
S
t
a
n
d
a
r
d
i
z
e
d
c
o
e
f
f
i
c
i
e
n
t
P
v
a
l
u
e
s
(
0
.
0
5
)
C
o
r
r
e
c
t
e
d
P
-
v
a
l
u
e
(
0
.
0
0
7
)
C
o
n
f
i
d
e
n
c
e
i
n
t
e
r
v
a
l
R
e
s
u
l
t
f
2
5
.
0
%
9
5
.
0
%
H1
P
E
→
PSC
0
.
7
1
9
0
.
0
0
0
*
0
.
0
0
0
*
*
0
.
6
5
2
0
.
7
8
7
S
u
p
p
o
r
t
e
d
1
.
0
4
3
H2
P
E
→
PO
0
.
0
1
9
0
.
4
3
5
ns
0
.
4
3
5
ns
-
0
.
1
6
3
0
.
2
2
4
N
o
t
s
u
p
p
o
r
t
e
d
0
.
0
0
0
H3
P
S
C
→
PO
0
.
6
0
6
0
.
0
0
0
*
0
.
0
0
0
*
*
0
.
4
4
4
0
.
7
4
7
S
u
p
p
o
r
t
e
d
0
.
2
9
6
H4
P
E
→
P
S
C
→
PO
0
.
4
3
6
0
.
0
0
0
*
0
.
0
0
0
*
*
0
.
3
2
4
0
.
5
4
5
S
u
p
p
o
r
t
e
d
-
H5
LS x
P
E
→
PSC
0
.
0
8
2
0
.
0
9
8
ns
0
.
0
9
8
ns
-
0
.
0
3
0
.
1
7
7
N
o
t
s
u
p
p
o
r
t
e
d
0
.
0
1
5
H6
LS x
P
E
→
PO
-
0
.
1
5
7
0
.
0
5
2
ns
0
.
0
5
2
ns
-
0
.
3
2
1
-
0
.
0
0
7
N
o
t
s
u
p
p
o
r
t
e
d
0
.
0
2
5
H7
LS x
P
S
C
→
PO
0
.
0
2
9
0
.
3
6
3
ns
0
.
3
6
3
ns
-
0
.
1
0
2
0
.
1
6
9
N
o
t
s
u
p
p
o
r
t
e
d
0
.
0
0
1
N
o
te
=
n
s
:
n
o
t
si
g
n
if
ica
n
c
e
,
*
:
si
g
n
ifi
c
a
n
c
e
a
t
p
-
v
a
lu
e
(
0
.
0
5
),
*
*
:
sig
n
ifi
c
a
n
c
e
a
t
c
o
rre
c
ted
p
-
v
a
l
u
e
0
.
0
0
7
),
P
S
C:
p
a
t
ien
t
sa
fe
ty
c
u
lt
u
re
,
P
O:
p
a
ti
e
n
t
o
u
tco
m
e
,
P
E:
p
s
y
c
h
o
l
o
g
ica
l
e
m
p
o
we
rm
e
n
t,
LS
:
len
g
t
h
o
f
se
rv
ice
T
h
er
e
ar
e
th
r
ee
m
o
d
er
atio
n
h
y
p
o
th
eses
,
H5
,
H6
,
an
d
H7
(
p
-
v
alu
e>
0
.
0
5
)
,
th
at
ass
ess
th
e
m
o
d
er
atin
g
r
o
le
o
f
len
g
th
o
f
s
er
v
ice,
wh
ich
n
ee
d
s
m
o
r
e
ev
id
e
n
ce
to
s
u
p
p
o
r
t
th
e
h
y
p
o
th
eses
.
Ho
w
ev
er
,
at
th
e
s
am
p
le
lev
el,
th
e
len
g
th
o
f
s
er
v
ice
w
ea
k
en
s
th
e
r
elatio
n
s
h
ip
b
etwe
en
PE
an
d
PO.
Me
an
wh
ile,
len
g
th
o
f
s
er
v
ice
ca
n
s
tr
en
g
th
en
PE
an
d
PS
C
,
as we
ll a
s
PS
C
-
to
-
PO r
elatio
n
s
h
ip
s
.
I
n
ad
d
itio
n
,
to
in
ter
p
r
et
th
e
h
y
p
o
th
eses
,
it’s
r
ec
o
m
m
en
d
e
d
t
o
co
n
s
id
er
ef
f
ec
t
s
ize.
T
h
e
r
esu
lts
o
f
th
e
h
y
p
o
th
eses
an
aly
s
is
,
it
was
f
o
u
n
d
th
at
lar
g
e
ef
f
ec
t
s
ize
(
f
2
=1
.
0
4
3
)
,
f
r
o
m
PE
to
PS
C
,
wh
ile
th
e
p
atien
t
s
af
et
y
cu
ltu
r
e
also
h
as a
m
ed
iu
m
ef
f
e
ct
o
n
p
atien
t o
u
tco
m
e
(
f
2
=0
.
2
9
6
)
.
So
,
th
e
r
elatio
n
s
h
ip
b
etwe
e
n
PE
an
d
PS
C
ca
n
b
e
s
aid
to
h
av
e
a
s
tr
o
n
g
r
elatio
n
s
h
ip
.
I
f
th
e
r
esp
o
n
d
en
t
h
as
o
b
tain
e
d
p
s
y
c
h
o
lo
g
ical
em
p
o
wer
m
en
t
f
r
o
m
th
e
h
o
s
p
ital,
th
en
th
e
p
atien
t saf
et
y
cu
ltu
r
e
will a
ls
o
in
cr
ea
s
e.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J
Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
P
a
tien
t sa
fety
cu
ltu
r
e
a
s
a
me
d
ia
to
r
b
etw
ee
n
h
ea
lth
c
a
r
e
…
(
E
ld
a
a
P
r
is
ca
R
efia
n
ti S
u
ta
n
to
)
1919
C
VPAT
b
ec
o
m
in
g
a
r
ec
en
t
ap
p
r
o
p
r
iate
m
eth
o
d
f
o
r
m
ea
s
u
r
in
g
th
e
p
r
ed
ictiv
e
ab
ilit
y
o
f
th
e
m
o
d
el
in
PLS
-
SEM
.
T
h
e
C
VPAT
also
r
ec
o
m
m
e
n
d
ed
m
ea
s
u
r
in
g
t
h
e
p
r
ed
ictio
n
-
o
r
ie
n
ted
m
o
d
el
c
o
m
p
ar
is
o
n
in
PLS
-
SEM
.
C
VPAT
en
s
u
r
es
th
at
th
e
o
v
er
all
m
o
d
el
ca
n
p
r
e
d
ict
th
e
d
ep
e
n
d
en
t
v
ar
iab
le
[
3
6
]
.
T
h
e
f
ir
s
t
co
m
p
ar
is
o
n
in
C
VPAT
aim
s
to
co
m
p
ar
e
PL
S
-
SEM
with
th
e
in
d
icato
r
av
er
ag
e
(
I
A)
.
B
y
r
esu
ltin
g
n
eg
ativ
e
v
alu
e,
t
h
e
I
A
in
d
icate
s
a
s
m
aller
er
r
o
r
in
th
is
m
o
d
el
an
d
s
h
o
ws
p
r
e
d
ictiv
e
v
alu
e,
T
h
e
n
,
th
e
s
ec
o
n
d
c
o
m
p
ar
is
o
n
aim
s
to
co
m
p
ar
e
PLS
-
SEM
with
th
e
l
in
ea
r
m
o
d
el
(
L
M)
an
d
b
y
r
es
u
ltin
g
in
a
n
eg
ativ
e
v
alu
e
in
P
L
S
-
SEM
in
d
icatin
g
s
tr
o
n
g
p
r
e
d
ictiv
e
ab
ilit
y
in
t
h
is
m
o
d
el.
B
ased
o
n
th
ese
f
in
d
in
g
s
,
it
co
n
clu
d
es
th
at
th
e
m
o
d
el
h
as
s
tr
o
n
g
p
r
ed
ictiv
e
r
elev
a
n
ce
an
d
ca
n
b
e
r
ep
licated
in
o
th
e
r
h
ea
lth
c
ar
e
p
er
s
o
n
n
el
-
r
elate
d
s
tu
d
y
[3
7
]
.
See
T
ab
le
7
f
o
r
d
etails.
T
ab
le
7
.
C
r
o
s
s
-
v
alid
ated
p
r
ed
i
ctiv
e
ab
ilit
y
test
r
esu
lt
V
a
r
i
a
b
l
e
s
P
LS SEM
v
s
I
A
P
LS SEM
v
s
L
M
A
v
e
r
a
g
e
l
o
ss
d
i
f
f
e
r
e
n
c
e
p
-
v
a
l
u
e
A
v
e
r
a
g
e
l
o
ss
d
i
f
f
e
r
e
n
c
e
p
-
v
a
l
u
e
P
a
t
i
e
n
t
o
u
t
c
o
m
e
-
0
.
0
4
0
0
.
0
1
8
-
0
.
0
0
8
0
.
0
7
2
P
a
t
i
e
n
t
s
a
f
e
t
y
c
u
l
t
u
r
e
-
0
.
3
3
2
0
.
0
0
0
-
0
.
0
1
4
0
.
2
1
1
O
v
e
r
a
l
l
-
0
.
1
7
3
0
.
0
0
0
-
0
.
0
1
1
0
.
0
6
2
T
h
e
h
eter
o
g
en
icity
an
al
y
s
is
was
d
o
n
e
u
s
in
g
f
in
ite
m
ix
tu
r
e
(
FIM
I
X)
an
al
y
s
is
.
R
esu
lti
n
g
in
two
co
m
p
ar
ab
le
s
eg
m
en
ts
th
at
h
a
v
e
s
ig
n
if
ican
t
d
if
f
er
en
ce
s
s
h
o
win
g
h
eter
o
g
en
icity
am
o
n
g
r
esp
o
n
d
en
ts
.
Fu
r
th
e
r
an
aly
s
is
in
p
atien
t
o
u
tco
m
e
s
eg
m
en
tatio
n
,
th
e
d
e
p
en
d
e
n
t
v
ar
iab
le,
th
at
s
h
o
ws
th
e
R
2
r
esu
lts
in
0
.
3
7
9
in
s
eg
m
en
t
1
an
d
0
.
9
9
7
in
s
eg
m
en
t
2
in
d
icate
s
th
at
a
d
d
itio
n
al
an
aly
s
is
n
ee
d
s
to
b
e
p
er
f
o
r
m
ed
to
ascer
tain
th
e
attr
ib
u
tes o
f
s
tu
d
y
r
esp
o
n
d
en
ts
,
ca
u
s
in
g
th
e
u
n
o
b
s
er
v
ed
h
eter
o
g
en
icity
,
s
ee
T
ab
le
8
.
T
ab
le
8
.
FIM
I
X
r
esu
lts
V
a
r
i
a
b
l
e
s
R
2
S
e
g
m
e
n
t
1
(
n
=
1
3
1
)
S
e
g
m
e
n
t
2
(
n
=
1
9
)
P
a
t
i
e
n
t
o
u
t
c
o
m
e
0
.
3
7
9
0
.
3
7
9
0
.
9
9
7
P
a
t
i
e
n
t
s
a
f
e
t
y
c
u
l
t
u
r
e
0
.
4
8
8
0
.
5
2
5
0
.
1
2
8
I
m
p
o
r
ta
n
ce
-
p
er
f
o
r
m
a
n
ce
m
a
p
(
I
PMA)
an
aly
s
is
was
u
s
ed
to
id
en
tif
y
in
d
icato
r
s
a
n
d
p
r
o
v
id
e
s
u
g
g
esti
o
n
s
to
m
an
ag
er
s
in
p
r
io
r
itizin
g
th
eir
im
p
r
o
v
e
m
en
t
a
ctiv
ities
[3
8
]
.
I
t
h
as
r
esu
lted
f
r
o
m
th
e
to
tal
ef
f
ec
t
an
d
p
e
r
f
o
r
m
an
ce
b
ased
o
n
th
e
m
ea
n
v
alu
e.
I
m
p
o
r
tan
ce
-
p
er
f
o
r
m
an
ce
m
ap
an
aly
s
is
is
d
iv
id
ed
in
to
4
q
u
ad
r
an
ts
,
wh
er
ea
s
th
e
f
o
cu
s
is
m
o
r
e
o
n
th
e
q
u
ad
r
a
n
t
wh
ich
is
im
p
o
r
tan
t
an
d
p
er
f
o
r
m
ed
.
Fig
u
r
e
3
s
h
o
ws
th
e
m
ap
p
in
g
o
f
in
d
icato
r
s
th
at
n
ee
d
to
b
e
m
a
in
tain
ed
r
esp
ec
tiv
ely
.
T
h
is
s
tu
d
y
s
h
o
ws
th
at
I
m
p
ac
t
f
o
llo
wed
b
y
co
m
p
ete
n
ce
in
d
icato
r
s
n
ee
d
to
b
e
f
o
c
u
s
ed
o
n
to
b
e
m
ain
tain
e
d
to
b
e
m
o
r
e
p
er
f
o
r
m
e
d
in
s
u
p
p
o
r
tin
g
Patien
t
Ou
tco
m
es.
On
e
o
f
th
e
lo
west
s
co
r
es
in
th
e
r
ef
l
ec
tiv
e
in
d
icato
r
o
f
I
m
p
ac
t
is
t
h
e
p
ar
ticip
a
n
t’
s
co
n
tr
o
l
o
v
er
wh
at
h
ap
p
en
s
in
m
y
d
ep
ar
tm
en
t.
Fig
u
r
e
3
.
I
m
p
o
r
tan
ce
-
p
e
r
f
o
r
m
an
ce
m
ap
a
n
aly
s
is
o
f
in
d
icato
r
s
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
1
3
,
No
.
4
,
Dec
em
b
er
20
24
:
1
91
2
-
1
92
3
1920
3
.
2
.
Dis
cus
s
io
n
T
h
is
s
tu
d
y
aim
ed
to
an
aly
ze
th
e
r
o
le
o
f
p
atien
t
s
af
ety
cu
ltu
r
e
as
a
m
ed
iato
r
f
r
o
m
p
s
y
ch
o
lo
g
ical
em
p
o
wer
m
en
t
t
o
p
atien
t
o
u
tc
o
m
e.
A
p
o
s
itiv
e
r
elatio
n
f
r
o
m
th
e
d
im
en
s
io
n
s
o
f
p
atien
t
s
af
ety
cu
ltu
r
e
is
also
s
u
p
p
o
r
ted
b
y
th
e
d
ev
elo
p
m
en
t
o
f
p
s
y
ch
o
l
o
g
ical
em
p
o
wer
m
e
n
t
p
r
o
v
i
d
ed
in
h
ea
lt
h
ca
r
e
f
ac
il
ities
.
As
ex
p
ec
ted
,
th
e
r
esu
lt
d
e
m
o
n
s
tr
ated
p
ati
en
t
s
af
ety
c
u
ltu
r
e
r
o
le
h
as
a
p
o
s
itiv
e
r
elatio
n
s
h
ip
b
etwe
en
p
s
y
ch
o
lo
g
ical
em
p
o
wer
m
en
t a
n
d
p
atien
t o
u
t
co
m
es.
T
h
is
s
tu
d
y
h
ig
h
lig
h
ts
th
at
em
p
o
wer
m
en
t
is
im
p
o
r
tan
t
in
h
u
m
an
r
eso
u
r
ce
s
an
d
m
an
a
g
em
e
n
t
p
r
ac
tice
s
in
ce
it
ca
n
d
ir
ec
tly
im
p
r
o
v
e
s
u
b
o
r
d
in
ate
p
er
f
o
r
m
a
n
ce
,
as
in
a
p
r
ev
io
u
s
s
tu
d
y
[
1
0
]
.
T
h
is
s
tu
d
y
f
o
u
n
d
th
at
PE
in
h
ea
lth
ca
r
e
p
er
s
o
n
n
el
h
as
a
p
o
s
itiv
e
r
elatio
n
s
h
ip
with
th
e
p
atien
t
s
af
ety
c
u
ltu
r
e
i
n
th
e
co
n
tex
t
o
f
p
r
iv
at
e
h
o
s
p
itals
.
T
h
ese
r
esu
lts
a
lig
n
with
th
e
p
r
e
-
ex
p
er
im
e
n
tal
s
tu
d
y
ab
o
u
t
d
e
v
elo
p
in
g
p
s
y
ch
o
l
o
g
ical
em
p
o
wer
m
en
t
an
d
p
atien
t
s
af
ety
c
u
ltu
r
e
i
n
T
u
r
k
ey
[
3
9
]
.
A
f
ter
r
ec
eiv
in
g
a
tr
ain
in
g
-
b
ased
em
p
o
w
er
m
en
t
p
r
o
g
r
am
to
em
p
o
wer
t
h
e
n
u
r
s
es
p
s
y
ch
o
l
o
g
ically
an
d
im
p
r
o
v
e
PS
C
p
er
ce
p
tio
n
s
in
n
u
r
s
es,
th
er
e
wer
e
im
p
r
o
v
em
en
ts
in
m
ea
n
in
g
an
d
co
m
p
eten
ce
,
team
wo
r
k
with
in
th
e
u
n
its
,
an
d
t
h
e
n
u
m
b
e
r
o
f
r
ep
o
r
ted
ev
e
n
ts
af
ter
im
p
lem
en
tin
g
th
e
em
p
o
wer
m
en
t
p
r
o
g
r
am
.
Un
lik
e
th
e
ex
p
er
im
en
tal
r
esear
ch
,
th
is
s
tu
d
y
s
h
o
wed
a
s
ig
n
if
ican
t
r
elatio
n
s
h
i
p
b
etwe
en
PS
C
an
d
p
atien
t
o
u
tco
m
e
v
ar
iab
les.
T
h
e
r
esu
l
ts
also
s
h
o
wed
a
s
tr
o
n
g
r
elatio
n
s
h
ip
b
etwe
en
p
s
y
ch
o
lo
g
ical
em
p
o
wer
m
en
t
a
n
d
p
atien
t
s
af
ety
cu
ltu
r
e
(
=
0
.
7
1
9
)
.
T
h
e
f
in
d
in
g
s
o
f
th
is
s
tu
d
y
in
d
icate
th
at
th
e
len
g
th
o
f
s
er
v
ice
ca
n
n
o
t
p
r
o
v
id
e
s
tr
o
n
g
e
v
id
en
ce
th
at
th
e
len
g
th
o
f
s
er
v
ice
ca
n
af
f
ec
t
m
o
d
er
atio
n
in
th
e
s
tr
u
ctu
r
al
m
o
d
el.
T
h
e
im
p
licatio
n
o
f
th
is
s
tu
d
y
en
co
u
r
ag
es
th
e
h
o
s
p
ital
m
an
ag
em
en
t
to
p
r
o
v
id
e
a
n
em
p
o
wer
m
en
t
p
r
o
g
r
a
m
,
s
in
ce
it will b
e
b
en
ef
icial
in
d
ev
elo
p
in
g
h
ea
lth
ca
r
e
p
er
s
o
n
n
el’
s
p
er
ce
p
tio
n
o
f
Me
a
n
in
g
,
b
elief
,
v
alu
e,
an
d
b
e
h
av
io
r
.
Awa
r
en
ess
o
f
h
ea
lth
ca
r
e
p
er
s
o
n
n
el’
s
a
b
ilit
ies
an
d
ca
p
ab
ilit
ies
to
d
o
m
o
r
e
in
th
eir
d
u
ty
,
willin
g
n
ess
,
an
d
f
o
r
titu
d
e
to
wo
r
k
in
a
jo
b
wh
er
e
th
ey
ca
n
u
s
e
th
eir
ab
ilit
ies
wh
en
th
ey
ar
e
s
u
r
e
o
f
th
eir
co
m
p
eten
cies
also
im
p
r
o
v
e
a
f
ter
th
e
em
p
o
wer
m
en
t
p
r
o
g
r
am
[
4
0
]
.
Mo
r
eo
v
er
,
th
is
s
tu
d
y
r
e
v
ea
led
co
m
p
eten
ce
h
as
im
p
o
r
tan
t
b
ased
o
n
I
PMA
an
aly
s
is
a
s
s
h
o
wn
in
F
ig
u
r
e
3
,
wh
ich
alig
n
s
with
th
e
p
r
ev
io
u
s
s
tu
d
y
th
a
t
m
en
tio
n
s
th
at
em
p
lo
y
ee
wh
o
f
ee
ls
co
m
p
eten
t
in
th
e
h
o
s
p
ital
an
d
p
er
ce
iv
es
th
eir
jo
b
a
s
m
ea
n
in
g
f
u
l
m
ay
p
r
o
v
id
e
ad
v
a
n
tag
es in
cr
ea
tin
g
PS
C
[
3
9
]
,
[
4
1
]
.
W
h
ils
t
PE
r
elate
s
p
o
s
itiv
ely
to
PS
C
,
th
e
r
elatio
n
s
h
ip
b
etwe
en
PE
an
d
Patien
t
Ou
tco
m
es
in
th
e
h
ea
lth
ca
r
e
s
ettin
g
h
as
n
o
s
ig
n
if
ican
t
d
ir
ec
t
ass
o
ciatio
n
.
T
h
ese
f
in
d
in
g
s
in
d
icate
th
at
P
E
ca
n
n
o
t
b
e
d
ir
ec
tly
r
elate
d
to
ce
r
tain
o
u
tco
m
es.
T
h
is
ca
n
b
e
in
ter
p
r
eted
th
at
PE
ac
tiv
ities
r
eq
u
ir
e
clea
r
s
u
b
jects,
in
th
e
co
n
ce
p
t
o
f
h
ea
lth
ca
r
e
th
e
s
u
b
jects f
o
cu
s
e
d
o
n
PE
ar
e
o
n
e
o
f
th
e
s
u
b
jects r
elate
d
to
p
atien
t saf
ety
.
T
h
i
s
f
in
d
in
g
is
d
if
f
er
en
t
f
r
o
m
p
r
ev
io
u
s
r
esear
ch
th
at
P
E
ca
n
b
e
d
ir
ec
tly
r
elate
d
to
p
a
tien
t
o
u
tco
m
es.
T
h
is
d
if
f
er
e
n
c
e
in
r
esu
lts
is
l
ik
ely
d
u
e
to
th
e
p
r
o
f
ile
o
f
th
e
r
esp
o
n
d
en
ts
in
th
is
s
tu
d
y
wh
er
e
th
e
ag
e
o
f
th
e
h
ea
lth
ca
r
e
p
er
s
o
n
n
el
in
th
is
s
tu
d
y
was
y
o
u
n
g
er
.
T
h
ese
y
o
u
n
g
er
p
er
s
o
n
n
el
ar
e
n
o
t y
et
em
o
tio
n
ally
s
t
ab
le
[
4
2
]
.
T
h
u
s
,
th
e
p
s
y
ch
o
l
o
g
ical
em
p
o
wer
m
en
t
m
e
d
iated
b
y
Sa
f
ety
C
u
ltu
r
e
ca
n
estab
lis
h
a
p
o
s
itiv
e
r
elatio
n
s
h
ip
to
Patien
t
Ou
tco
m
es.
T
h
e
r
esu
lts
o
f
th
is
s
tu
d
y
ca
n
f
ill
th
e
lim
itatio
n
s
o
f
p
r
ev
io
u
s
r
esear
ch
,
wh
ich
h
as
n
o
t
ex
p
lain
ed
m
u
ch
a
b
o
u
t
th
e
r
elatio
n
s
h
ip
b
etwe
en
th
e
m
ed
iatin
g
r
o
le
o
f
p
atien
t
s
af
et
y
cu
ltu
r
e
i
n
PE
an
d
PO.
Pre
v
io
u
s
s
tu
d
ies
h
av
e
i
n
d
ee
d
s
tated
th
at
PE
is
m
ed
iatin
g
in
in
cr
ea
s
in
g
th
e
s
ig
n
if
ican
t
r
elatio
n
s
h
ip
E
m
o
tio
n
al
I
n
tellig
en
ce
h
as
o
n
q
u
ality
o
f
s
er
v
ice
an
d
wo
r
k
s
y
s
tem
p
er
f
o
r
m
an
ce
with
q
u
ality
p
atien
t
ca
r
e.
Ho
wev
er
,
s
tu
d
ies
o
n
th
e
d
ir
ec
t
r
elatio
n
s
h
ip
b
etwe
en
p
s
y
c
h
o
lo
g
ical
em
p
o
we
r
m
en
t
a
n
d
p
ati
en
t
o
u
tco
m
es
h
av
e
n
o
t b
ee
n
co
n
d
u
cted
b
ef
o
r
e
[
2
0
]
,
[
4
3
]
.
I
n
ter
m
s
o
f
th
e
d
im
en
s
io
n
al
an
aly
s
is
o
f
P
SC
,
th
is
s
tu
d
y
’
s
f
in
d
in
g
s
ex
h
ib
it th
e
s
am
e
r
esu
lt a
s
p
r
ev
io
u
s
s
tu
d
ies
wh
er
e
jo
b
s
atis
f
ac
tio
n
is
th
e
s
ec
o
n
d
m
o
s
t
im
p
o
r
t
an
t
co
m
p
o
n
e
n
t
as
a
d
im
en
s
i
o
n
o
f
p
atien
t
s
af
ety
cu
ltu
r
e.
Ps
y
ch
o
lo
g
ical
em
p
o
w
er
m
en
t
is
o
n
e
o
f
th
e
well
-
k
n
o
wn
im
p
o
r
tan
t
p
r
ed
icto
r
s
o
f
jo
b
s
atis
f
ac
tio
n
.
T
h
is
s
tu
d
y
alig
n
s
with
a
p
r
ev
io
u
s
s
tu
d
y
d
o
n
e
in
Sau
d
i
Ar
ab
ia
n
I
C
U
Saf
ety
C
u
ltu
r
e
in
2
0
1
2
,
wh
ich
f
o
u
n
d
jo
b
s
atis
f
ac
tio
n
also
b
ec
am
e
th
e
h
ig
h
est
s
co
r
e
in
co
n
tr
ib
u
tin
g
to
Saf
ety
C
u
ltu
r
e
in
I
C
U
[
2
]
,
[
1
2
]
.
T
h
e
r
e
ar
e
em
er
g
in
g
tr
en
d
s
th
at
r
elate
to
co
n
n
ec
tio
n
s
b
etwe
en
p
atien
t
s
af
ety
cu
ltu
r
e
a
n
d
s
p
ec
if
ic
p
ati
en
t
o
u
tc
o
m
es.
T
h
is
in
f
o
r
m
atio
n
f
r
o
m
p
r
e
v
io
u
s
s
tu
d
ies
g
u
id
es
r
esear
ch
er
s
in
th
is
s
tu
d
y
to
co
n
s
tr
u
ct
th
e
r
ec
e
n
t
v
alid
atio
n
o
f
th
e
im
p
o
r
tan
ce
o
f
a
p
o
s
itiv
e
p
atie
n
t
s
af
ety
c
u
ltu
r
e
[
2
9
]
.
T
h
e
r
es
u
lts
th
at
y
ield
ed
a
s
ig
n
if
ica
n
t
r
elatio
n
s
h
ip
b
etwe
en
p
atien
t saf
ety
cu
ltu
r
e
a
n
d
p
atien
t o
u
tco
m
es a
r
e
o
u
tlin
ed
in
Fig
u
r
e
2
.
T
ea
m
wo
r
k
clim
ate
is
th
e
d
im
en
s
io
n
al
an
aly
s
is
o
f
PS
C
,
wh
i
ch
h
as
th
e
m
o
s
t
p
er
f
o
r
m
an
ce
v
ar
iab
le
in
I
PMA
an
aly
s
is
.
On
th
e
o
t
h
er
s
id
e,
th
e
wo
r
k
i
n
g
clim
ate,
o
n
e
o
f
th
e
d
im
e
n
s
io
n
al
a
n
aly
s
es
o
f
PS
C
,
s
till
m
u
s
t
b
e
f
o
cu
s
ed
o
n
an
d
d
ev
el
o
p
ed
t
o
b
ec
o
m
e
m
o
r
e
p
e
r
f
o
r
m
ed
in
t
h
e
I
PMA
p
er
f
o
r
m
an
ce
in
d
icato
r
in
Fig
u
r
e
3
.
T
h
is
r
esu
lt
ca
n
p
e
r
h
ap
s
b
e
ex
p
lain
ed
b
y
n
o
n
ex
is
ten
t
team
tr
ai
n
in
g
in
h
o
s
p
itals
[
2
5
]
,
[
2
8
]
,
[
4
4
]
.
T
h
is
s
tu
d
y
is
co
n
s
is
ten
t
with
th
e
f
in
d
in
g
f
r
o
m
a
p
r
ev
io
u
s
s
tu
d
y
in
Au
s
tr
ia
th
at
h
as
s
h
o
wn
th
e
r
elatio
n
s
h
ip
b
etwe
en
team
wo
r
k
with
in
u
n
its
an
d
cl
in
ical
p
atien
t
o
u
tco
m
es,
in
clu
d
in
g
er
r
o
r
r
ates
an
d
p
atien
t
m
o
r
tality
th
er
ef
o
r
e,
h
o
s
p
ital
m
an
ag
e
m
en
t
s
h
o
u
ld
im
p
lem
en
t
team
tr
ain
in
g
to
im
p
r
o
v
e
team
wo
r
k
with
in
u
n
i
ts
.
T
h
e
team
wo
r
k
clim
ate
co
n
s
is
ts
o
f
th
e
in
d
icat
o
r
s
o
f
co
m
m
u
n
icatio
n
an
d
f
ee
d
b
ac
k
i
n
th
e
h
ea
lth
ca
r
e
u
n
it;
t
h
e
h
ig
h
s
co
r
e
o
f
th
is
s
tu
d
y
ca
n
b
e
d
escr
ib
ed
as
a
s
af
e
en
v
i
r
o
n
m
e
n
t
f
o
r
o
p
in
i
o
n
s
a
n
d
a
lo
w
b
lam
in
g
cu
ltu
r
e
in
th
e
h
o
s
p
ital
[
3
]
,
[
4
5
]
.
Patien
t
s
af
ety
is
a
cr
itical
co
m
p
o
n
e
n
t
o
f
im
p
r
o
v
in
g
p
atien
t
o
u
tco
m
es.
As
h
ea
lth
ca
r
e
f
ac
ilit
ies
co
n
tin
u
ally
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J
Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
P
a
tien
t sa
fety
cu
ltu
r
e
a
s
a
me
d
ia
to
r
b
etw
ee
n
h
ea
lth
c
a
r
e
…
(
E
ld
a
a
P
r
is
ca
R
efia
n
ti S
u
ta
n
to
)
1921
s
tr
iv
e
to
im
p
r
o
v
e,
th
e
r
e
is
a
g
r
o
win
g
r
ec
o
g
n
itio
n
o
f
th
e
i
m
p
o
r
tan
ce
o
f
estab
lis
h
in
g
a
s
af
ety
cu
ltu
r
e
an
d
th
e
r
o
le
o
f
p
s
y
ch
o
lo
g
ical
em
p
o
we
r
m
en
t in
h
ea
lth
c
ar
e
p
e
r
s
o
n
n
el
[
7
]
,
[
1
7
]
.
T
h
is
s
tu
d
y
h
as
s
ev
er
al
lim
itatio
n
s
,
f
ir
s
tly
a
s
m
all
s
am
p
le
s
ize
o
f
t
h
is
s
tu
d
y
wh
ich
is
o
n
ly
o
n
e
p
r
iv
ate
h
o
s
p
ital.
Seco
n
d
ly
,
th
e
h
eter
o
g
en
icity
;
th
er
ef
o
r
e
,
p
o
s
t
h
o
c
an
aly
s
is
s
h
o
u
ld
b
e
d
o
n
e
to
an
al
y
ze
th
e
attr
ib
u
te
o
r
ch
ar
ac
ter
is
tic
r
esp
o
n
d
en
t
t
h
at
af
f
ec
ts
th
e
h
eter
o
g
e
n
icity
o
f
d
ata.
T
h
ir
d
ly
,
t
h
e
d
ata
co
llectio
n
u
s
ed
o
n
lin
e
s
elf
-
ad
m
in
is
ter
ed
q
u
esti
o
n
n
air
es
p
r
o
n
e
to
b
ias.
T
h
er
ef
o
r
e,
in
th
e
f
u
tu
r
e
,
th
e
s
tu
d
y
is
r
ec
o
m
m
en
d
ed
t
o
u
s
e
d
ir
ec
t
in
ter
v
iews
to
c
o
llect
d
ata
f
r
o
m
p
ar
ticip
a
n
ts
.
L
astl
y
,
t
h
e
r
es
p
o
n
d
e
n
ts
wer
e
n
o
t
class
if
ied
b
ased
o
n
p
er
s
o
n
ality
.
Ps
y
ch
o
lo
g
ical
em
p
o
wer
m
en
t
is
k
n
o
w
n
to
b
ec
o
m
e
m
o
r
e
ef
f
ec
tiv
e
f
o
r
p
e
o
p
le
with
c
er
tain
p
er
s
o
n
alities
;
th
er
ef
o
r
e,
in
f
u
tu
r
e
s
tu
d
ies,
p
e
r
s
o
n
ality
tr
aits
co
u
ld
b
e
d
ep
lo
y
ed
as a
m
o
d
er
atin
g
v
ar
iab
le.
4.
CO
NCLU
SI
O
N
T
h
is
s
tu
d
y
co
n
clu
d
es
th
at
p
a
tien
t
s
af
ety
cu
ltu
r
e
p
la
y
s
an
ess
en
tial
r
o
le
in
m
ed
iatin
g
th
e
p
o
s
itiv
e
r
elatio
n
s
h
ip
b
etwe
en
th
e
p
s
y
c
h
o
lo
g
ical
em
p
o
wer
m
en
t
o
f
m
ed
ical
p
er
s
o
n
n
el
with
p
atien
t
o
u
tco
m
es.
T
h
is
is
r
ein
f
o
r
ce
d
b
y
th
e
f
in
d
i
n
g
s
,
w
h
ich
s
h
o
w
t
h
e
ty
p
e
o
f
m
ed
ia
tio
n
is
f
u
ll
m
e
d
iatio
n
.
T
h
is
s
tu
d
y
in
d
icate
s
th
at
h
ea
lth
ca
r
e
p
er
s
o
n
n
el
wh
o
f
ee
l
em
p
o
wer
e
d
will
d
em
o
n
s
tr
ate
in
v
o
lv
em
e
n
t
in
a
p
at
ien
t
s
af
ety
c
u
ltu
r
e.
Fu
r
th
er
m
o
r
e
,
p
atien
t
s
af
ety
c
u
ltu
r
e
will
b
e
r
elate
d
to
im
p
r
o
v
in
g
p
atien
t
o
u
tco
m
es,
f
o
r
ex
am
p
le,
av
o
id
in
g
p
atien
t
p
h
y
s
ical
d
am
a
g
e
s
u
ch
as
f
alls
an
d
p
r
ess
u
r
e
s
o
r
es
an
d
p
atien
t
ch
em
ical
d
am
ag
e
s
u
ch
as
d
r
u
g
m
is
u
s
e,
d
r
u
g
i
n
co
m
p
atib
ilit
y
,
an
d
wr
o
n
g
m
ed
icatio
n
.
T
h
is
s
tu
d
y
h
as
o
f
f
er
e
d
a
n
ew
ap
p
r
o
ac
h
to
m
ea
s
u
r
in
g
th
e
d
i
m
en
s
io
n
ality
o
f
PE
an
d
PS
C
t
h
r
o
u
g
h
th
e
d
is
jo
in
t
two
-
s
tag
e
ap
p
r
o
ac
h
.
T
h
r
o
u
g
h
th
is
m
eth
o
d
,
t
h
e
r
esu
lt
s
h
o
ws
th
e
im
p
o
r
tan
t
d
im
en
s
io
n
s
th
at
s
h
o
u
ld
b
e
p
r
io
r
itized
b
y
h
o
s
p
ital
m
a
n
ag
em
en
t
wh
ich
ar
e
I
m
p
ac
t
as
a
d
im
en
s
io
n
o
f
p
s
y
c
h
o
lo
g
ical
em
p
o
wer
m
en
t
an
d
Saf
ety
clim
ate
as
a
d
im
e
n
s
io
n
o
f
p
atien
t
s
af
ety
cu
ltu
r
e.
Fin
ally
,
th
is
s
tu
d
y
co
u
ld
s
u
g
g
est
th
at
h
o
s
p
ital
m
an
ag
em
en
t
f
o
cu
s
es
o
n
th
e
p
s
y
ch
o
lo
g
ical
em
p
o
wer
m
en
t
ap
p
r
o
ac
h
,
wh
ich
ca
n
s
u
p
p
o
r
t
f
o
r
m
in
g
a
p
atien
t
s
af
ety
cu
ltu
r
e.
Sp
ec
if
ically
,
th
is
ap
p
r
o
a
ch
co
u
ld
b
e
im
p
lem
en
ted
b
y
in
-
h
o
u
s
e
tr
ain
i
n
g
a
n
d
m
o
tiv
atin
g
h
ea
lth
ca
r
e
p
er
s
o
n
n
el
ab
o
u
t th
e
ir
im
p
o
r
tan
t
r
o
le
in
im
p
r
o
v
in
g
p
atien
t o
u
tco
m
es.
RE
F
E
R
E
NC
E
S
[
1
]
G
.
A
l
S
a
l
e
m,
P
.
B
o
w
i
e
,
a
n
d
J.
M
o
r
r
i
so
n
,
“
H
o
s
p
i
t
a
l
s
u
r
v
e
y
o
n
p
a
t
i
e
n
t
s
a
f
e
t
y
c
u
l
t
u
r
e
:
p
s
y
c
h
o
met
r
i
c
e
v
a
l
u
a
t
i
o
n
i
n
K
u
w
a
i
t
i
p
u
b
l
i
c
h
e
a
l
t
h
c
a
r
e
set
t
i
n
g
s,”
B
MJ
O
p
e
n
,
v
o
l
.
9
,
n
o
.
5
,
p
.
e
0
2
8
6
6
6
,
M
a
y
2
0
1
9
,
d
o
i
:
1
0
.
1
1
3
6
/
b
mj
o
p
e
n
-
2
0
1
8
-
0
2
8
6
6
6
.
[
2
]
A
.
S
.
A
l
a
y
e
d
,
H
.
Lö
ö
f
,
a
n
d
U
.
-
B
.
J
o
h
a
n
ss
o
n
,
“
S
a
u
d
i
A
r
a
b
i
a
n
I
C
U
s
a
f
e
t
y
c
u
l
t
u
r
e
a
n
d
n
u
r
s
e
s’
a
t
t
i
t
u
d
e
s
,
”
I
n
t
e
r
n
a
t
i
o
n
a
l
J
o
u
rn
a
l
o
f
H
e
a
l
t
h
C
a
r
e
Q
u
a
l
i
t
y
A
ssu
r
a
n
c
e
,
v
o
l
.
2
7
,
n
o
.
7
,
p
p
.
5
8
1
–
5
9
3
,
A
u
g
.
2
0
1
4
,
d
o
i
:
1
0
.
1
1
0
8
/
I
JH
C
Q
A
-
04
-
2
0
1
3
-
0
0
4
2
.
[
3
]
Š
.
D
r
a
g
a
n
o
v
i
ć
a
n
d
G
.
O
f
f
e
r
ma
n
n
s,
“
P
a
t
i
e
n
t
safe
t
y
c
u
l
t
u
r
e
i
n
A
u
s
t
r
i
a
a
n
d
r
e
c
o
m
me
n
d
a
t
i
o
n
s
o
f
e
v
i
d
e
n
c
e
-
b
a
s
e
d
i
n
s
t
r
u
m
e
n
t
s
f
o
r
i
mp
r
o
v
i
n
g
p
a
t
i
e
n
t
safe
t
y
,
”
PLO
S
O
N
E
,
v
o
l
.
1
7
,
n
o
.
1
0
,
p
.
e
0
2
7
4
8
0
5
,
O
c
t
.
2
0
2
2
,
d
o
i
:
1
0
.
1
3
7
1
/
j
o
u
r
n
a
l
.
p
o
n
e
.
0
2
7
4
8
0
5
.
[
4
]
J.
C
a
m
p
i
o
n
e
a
n
d
T.
F
a
m
o
l
a
r
o
,
“
P
r
o
m
i
si
n
g
p
r
a
c
t
i
c
e
s
f
o
r
i
mp
r
o
v
i
n
g
h
o
s
p
i
t
a
l
p
a
t
i
e
n
t
s
a
f
e
t
y
c
u
l
t
u
r
e
,
”
T
h
e
J
o
i
n
t
C
o
m
m
i
ssi
o
n
J
o
u
rn
a
l
o
n
Q
u
a
l
i
t
y
a
n
d
Pa
t
i
e
n
t
S
a
f
e
t
y
,
v
o
l
.
4
4
,
n
o
.
1
,
p
p
.
2
3
–
3
2
,
Ja
n
.
2
0
1
8
,
d
o
i
:
1
0
.
1
0
1
6
/
j
.
j
c
j
q
.
2
0
1
7
.
0
9
.
0
0
1
.
[
5
]
S
.
E
.
Le
e
,
L.
D
.
S
c
o
t
t
,
V
.
S
.
D
a
h
i
n
t
e
n
,
C
.
V
i
n
c
e
n
t
,
K
.
D
.
Lo
p
e
z
,
a
n
d
C
.
G
.
P
a
r
k
,
“
S
a
f
e
t
y
c
u
l
t
u
r
e
,
p
a
t
i
e
n
t
s
a
f
e
t
y
,
a
n
d
q
u
a
l
i
t
y
o
f
c
a
r
e
o
u
t
c
o
mes
:
a
l
i
t
e
r
a
t
u
r
e
r
e
v
i
e
w
,
”
W
e
st
e
r
n
J
o
u
rn
a
l
o
f
N
u
rsi
n
g
Re
s
e
a
r
c
h
,
v
o
l
.
4
1
,
n
o
.
2
,
p
p
.
2
7
9
–
3
0
4
,
F
e
b
.
2
0
1
9
,
d
o
i
:
1
0
.
1
1
7
7
/
0
1
9
3
9
4
5
9
1
7
7
4
7
4
1
6
.
[
6
]
H
.
F
.
D
i
r
i
k
a
n
d
S
.
S
.
I
n
t
e
p
e
l
e
r
,
“
T
h
e
w
o
r
k
e
n
v
i
r
o
n
m
e
n
t
a
n
d
e
mp
o
w
e
r
m
e
n
t
a
s
p
r
e
d
i
c
t
o
r
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