(QUALITY GRAND ROUNDS Sees Editors: Rober M. Wacher, MD; Kaveh G. Shoenis, MD; ACADEMIA AND CLINIC Sanjay Sunt, MD, MPH; Amy J. Markowiez, JD; nd Matk Smith, MD, MBA The Wrong Patient ‘Mark R. Cassia, MD, MPP, MAPH, and lige C. Bechet, MD, MA* ‘Among all types of medical eros, eases in which the wrong patient undergoes an invasive procedure are sufficiently distress. ing to warrant specal attention, Nevertheless, institutions under report such procedure, and the modieal erature contains #0 Aiscussions about them. This ace examines the case of a patent who was mistakenly taken for another pale’ invasive electo- hystology procedure. After reviewing the case and the results of the institution's “root-cause analysis,” the discussans discovered at least 17 dlstinet enors, no single one of which could have ‘caused this adverso event by itself. The dscussantsiturrate how these specie “active” enor infected with afew undying “letet condtions" (sytem weaknese) to cause han. The most Temedale ofthese ware absent or missed protools fr paint entiation and ifomed consent, systematically faulty er change of infomation among caregves, and poy functioning teams denen tes 0c 362688, For asso, eed lt See edtoril commnt on pp 650-852. ‘nesanied estnof be at aia vars ue “Quality Grand Rownds” is a series of articles and come panion confirenes designed to explore a range of quality itoues and medical errors, Presenting actual cases drawn from institutions around the United States, the artder ine regrate traditional medical case bictrie with results of root cause analyes and, where appropriate anonymous in terviews with the involved patiens, physicians, names, and ‘sk managers. Cases do not come from tbe discasans’ beome instivutons, SUMMARY OF EvetiTs Joan Moris (a pseudonym) is @ 67-yearold women ‘admitted to a teaching hospital for cerebral angiography. The day after that procedure, she mistakenly underwent an ‘invasive cardiac electrophysiology study. The patient, a nasive Englich speaker and high school _sraduate whose daughter i a physician, had been well until several months earlier, when she fll and struck her head. Magnetic resonance imaging showed two larg cerebral an ceuryrms. The interventional radiology service admitted her for cerebral angiography. The day efter admixion, cerebral angiography wis per formed, and one of the ancurpms was succesfully emboli. sed. The second aneuryom was deemed more amenable 0 surgical therapy, for which a subsequent admision was planned. Afier angiography, the patient was transfered 19 the oncology flor rather than resurning to her original bed on the telemetry unis. Discharge wat planned forthe fol- lowing day. The next morning, however, the patient was taken for an invasive eardiae elecrophyiology stidy. Ap- proximately 1 hour into the procedure, it became apparent that Ms Morris was the wrong patient. The study was caborted, and she was returned ta ber voor in stable condi ton. PERFORMING AN INVASIVE PROCEDURE ON THE Wronc Patient Of all of the errors we make in delivering health care this case surely represents one of the most disturb- ing. Despite occasional local news coverage of such ed~ verse events (1-3), few data are available to document their incidence, The Joint Commission on Accreditation of Healthcare Organizations maintains a national dara- base of “sentinel events” (4, 5), which include errors such as chis one, Reporting to the Joint Commission is Voluntary; the database contains 17 reports of an inva- sive procedure done on the wrong patient over the past 7 years (Schyve P, Personal communication, 31 January 2002), Additional information about adverse events is compiled by individual states, at least 15 of which main- tain their own crror-reporting systems (6). New York State has a long-standing and recently revised manda- tory reporting system; it has received reports of 27 “in- correct patient/invasive procedure” incidents from April 1998 through December 2001 (Heigel P. Personal com- ‘munication, 14 February 2002). ‘The marked disparity in the number of events chronicled by these two databases—one voluntary, one “This pp ws pep by Nak . Clann, MD, MPD, MDG, nd ie © Baden MD) mee {8260 20 Avian Calle of Pine Arsen Scene Malina MA ft he Quay evn Rods ez Kah Sho, MD, pnd oemandatory—suggests that the voluntary Join Commis- sion database is incomplete (5). But even mandatory state reporting systems may underestimate the true inci- dence of “wrong-patient” procedures. All errorreport- ing systems depend on hospitals’ incernal incident re- ports as sources for theit data, and research has shown that clinicians fle incident reports for only a small per- centage of actual errors (7-9). A recent analysis of the New York system, for example, determined chat for one of the adverse events for which reporting is required (eaths within 48 hours of surgery), only 16% of cases were reported in 1999 (10, 11). ‘The medical literature is largely silent about this problem, We found a small number of studies showing errors of patient misidentification in the transfusion of blood products (12), injection of radionuclide material (13), and administration of chemotherapy (14), We ‘could not find a single study or case eport on the prob- Jem of wrong-patient invasive procedures. Although the New York data may provide a lower bound frequency ‘estimate, given the dearth of research and the limitations of error-reporting systems, we conclude that we do not know how often this type of event occurs, However rarely these events occur, all health care delivery syseems should stive to eliminate them entirely. ‘Cironovocy oF Events Another patiens, a 77-year-old woman with a snilar name (lane Morrivon, a preudonym) had been tranférred Som an outide hospital for a cardiac eleerophyiolegypro- cedure and was alo advmisted 20 the telemetry unit. Mn Morrison’ procedure, which had been delayed for 2 days, swat schediled asthe firs electrophysiolegy cae forthe early ‘morning of he day of Ms, Morrir’s planned discharge GIS a.m, The electrophysology nurse (RN,) logged on 40 the electroplysiolegy laboratory computer to check the torming schedule and saw Jane Morrison listed asthe fst ease, (The dleirophysiology laboratory's computer sytem is separate ftom the main hospital sytem and does nat ee change information with it) RN, telephoned the telemetry oor, identified herself by name, and asked far “patient Morrison” (Going no other identifying information). The Person ansvering the telephone (never identified) incorrectly ssased that Ms. Morrison bad been moved tothe onlay floor, when she ws, in fact, ell on the telemetry flor 6:20 asm. RN, called the oncology floor, where Joan vag ‘The Wrong Petint | ACADEMIA AND CLINIC ‘Morris had been transferred after her cerebral angiography. RN, swas mistakenly informed thas the patent she sought (lane Morrison) was there, and she was tld that the pa ent would be transported to the elecrrophysiclegy labora ory. 6:30 aum, Joan Morris's nurse, RN (who was nearing the end of her shift), agreed to transport the patient forthe eletrophypalogy procedure, although neither the charge amurse nor Ms, Morris's nurse from the previous evening had sold her of a plan for an elecrophysilogy procedure. RN, casstmed that the study had been arranged despite the ab. sence of a sritien order for it in the chart. Ms. Morris stated shat she was unausare of plas for an elecrophysiology procedure, she did not want t0 undergo it, and she wes nauseated. RN informed the patient that she could refise the procedure aftr she arrived in the electroplysiology lab- 645 a.m, RN brought Ms, Morris to the electroplys- ‘ology laboratory along with her chart After tht patient ‘agtin expresed reluctance to undergo the procedie, the lectrophysology nurse, RN, paged the elecrrpysiology at- tending who renumed the page promptly. He asked 0 speak with the patins, who again stated that the was nauseated sand fels generally unuell. The attending had briefly met Jane Morrison (the corrce patient) the nigh before but did not realize he was now speaking with a different patent He was somewhat surprised to bear of her reluctance 19 undergo the procedure because she had not exprased this concern the nighs before. Afler speaking with Ms. Morris, ‘ie instructed RN, t0 administer insravenous prociorpera. ine for nausea and stated that the patient had agreed 10 proceed, 45 10 7:00 a.m, RN; reviewed the chart accompa sping the patient and noticed no consens form, eventhough the daily schedule stated that consent had been obtained. ‘She paged the elecrophysiolegy flow scheduled to do the procedure. 7:00 to 7:15 am. Upon arrival, the fellow reviewed the chart and was surprised at its relative lack of pertinent information. However, the fellow then discussed the proce dure swith the patient and had er sign the consent for “EP Study with ponible ICD and pasible PM placement” (EP = electophyriolegs ICD = implantable cardige de- Fibrilator; PM = pacemaker). A per diem nurse in the clectrophwiology ldboratory, RNy wimesed the consent Prochlorperazine was given after Mz. Morris signed the consent form. 4 Jo 2 ental Metin 136» Nae 7ACADEMIA AND CLINIC | The WrongPadent UninrormeD Consent How could Ms. Morris, a native English speaker and a high school graduate, have signed a consent form for a procedure she knew she was not supposed to un- dergo—a consent form that indicated her agreement to possible cardiac surgery to implant a defibrillator? In theory, the process of informed consent should protect both patients and caregivers from adverse events such as this by providing patients the information they need to become full participants in decisions about their care. In practice, however, the process of obtaining informed consent is often deeply flawed. Obtaining consent is fre~ quently delegated to an overburdened or exhausted phy- sician who has not met the patient previously and does not know the details of the medical history. Cultural or social bartiers to effective communication may be nei- ther appreciated nor overcome. Although expected ben- fits and risks may be briefly described, truly involving the patient in the decision-making process is often not @ twp priority (15). Patients fequently cannot recall cru- cial information about procedures within hours of giv- ing consent (16-18), In two studies conducted more than a decade apart, moze than 60% of patients sur- veyed about their experiences with the consent process said they believed that consent forms are intended to protect physicians’ rights (19, 20), So why did Ms. Mortis sign the consent form? Could she have thought she was agreeing to the surgery ‘o repair the second aneurysm that had been planned for a subsequent hospital stay? Pechaps. But if the electro- physiology fellow had thoroughly explained the electro- physiology study, itis difficult to imagine that the pa- tiene would have confused the two procedures. Ms, Morris did sign the form, but she clearly did not give “informed consent.” CuronoLocy oF Events, ConriNueD 7:10 am. The elecrophysiology charge nurse arrived cand was told by RN, that a patient scheduled for an early stare bad arrived. No patient name was uied in this con= versation, The charge nurse checked the elecorophysiology schedisle and shen lef to astend to other duties. 7:15 to 7:30 a.m. RN, placed the patient on the table, attached monitors, and spoke tothe patient about her pro cedure. Mz Morris stated shat she bad “fainted.” which 24 Jn 202 Anetta Med Vane 156+ Nabe seemed to RN; t0 be a reatonable indication for an electro physilogy procedure, 7:30 arm A resident from the neurosurgery team on bis morning rounds was surprised to find Mi, Morris out of ber roam. Afier learning ofthe elecirophysiology procedure, te came down to the elecrophysiology laboratory and de- manded to know “why my patiens” (not using her name] twas there, a he wat unaware of an order for this procedure, RN, informed the resident that the patient had been bumped twice already but was now being taken as the fst case of the day. The resident lee the electrophyiology labo- ratory assuming that his attending had ordered the study without telling him. 8:00 aim, An additional electrophysiology nurse (RN) cand the electrophysiology anending arrived. The axtending stood cutie the procedure room a the computer console sand could not see the patients face because her head was dvaped. The fllow initiated the procedure, inserting fomo- ral sheaths and beginning programmed stimulation ofthe heart via an intracardiac electrophysiology catheter. 4:30 10 8:43 asm. A nurse fiom the telemeny floor, RN telephoned the electrophysiology laboratory to find out thy wo one had caled for Jane Morrison (he correct par tient), RNg took she call and, after consulting with RN atbous she expected completion time for the current cate Goan Morris), advised RN, t send Mt. Morrison down at 10am. 8:30 to 8:45 a.m. The electrophysiology charge nurse, ‘making pavens stickers for the morning cases, noticed that ‘Joan Morris” did not match any ofthe five names bted in the morning log. Entering the electrophysiology laboratory, she questioned she fillow abous the pasient names. He sid, “This is our patent.” Because the procedure was ata teche nically demanding juncture, she charge nurse did not pur- swe the conversation further, assuming that Ms. Morris had ‘ben added aftr the advance schedule had been distributed. 9:00 to 9:15 a.m. Like the neurosurgery resident 90 sinuses earlier, an interoentional radiology attending went 0 Mi. Morris's room and was surprised to find it empty. He called the clectroplsiology laboratory +0 atk why Ms, Morris was undergoing this procedure. The electrophyiol- ‘ogy attending stated to the nurse that the call concerned a patient named Morris, but that Jane Morvison was on the table. The electrophysiology charge nurse corrected him, stating that, in fict, Joan Morris was on the table. The clecrroplysiology attending asked to see the patients chart sand recogniced the erro. vasei 915 to 9:50 am. The study was aborted, and the patient was returned to the oncology floor in stable cond- tion. The eleccrophysiology attending explained the error to the patie and her family, The patient stayed in the bos- ital overnigh for obsroation and was discharged the next ‘day, She was scheduled for outpatient neurorurgical fol- ove-up to arrange surgery for her remaining ancurym: Disciosinc EnRors To begin at the end, one of the many fearues of this case that deserves emphasis is the commendably im- ‘mediate and complete disclosure of the exor. We must ‘overcome aay temptation to be less than filly candi The ethical imperative to inform patients and families when errors lead to adverse events overwhelms all other considerations. ‘THE RoLts OF INDIVIDUALS AND SYSTEMS IN CAUSING ‘Tuis Apverse Event ‘On first reading, one may be tempted eo blame this adverse event on any one of several individuals, from the nurse who mistakenly brought Joan Mortis to the elec- ‘wophysiology laboratory (RNG) to the clectrophysiology attending physician who failed to introduce himself to the patient at the start of the procedure. A closer analysis reveals problems beyond individual errors, To be sure, individuals made errors. In fact, discrete erors occurred in at least 17 different places. (See Appendix Table 1, available at wwww-annalsorg,) But this event shares many characteristics with other well-known and exhaustively researched calamities, such as the Challenger disaster, the Chernobyl nuclear reactor explosion, and the Bho- pal chemical factory catastrophe. These events have been termed “organizational accidents” by psychologist and accident expert James Reason because they happen to complex, modern organizations, not to individuals (21, 22). No single individual error is sufficiently grave to cause an organizational accident. The errors of many individuals ("active exzors") converge and interact with system weakmesses (“lent conditions”), increasing the likelihood that individual errors will do asm. Understanding why Ms. Morris mistakenly under- went the electrophysiology procedure requires looking beyond the actions of individuals to factors affecting the functioning of the systems in which the individuals acted. It is imporeant to distinguish between two groups somes ‘The Wrong Patient | ACADEMIA AND CLINIC of these factors. Environmental factors are not readily changeable, a least in the short run, and thus they form the fixed context in which systems and people function. They act of all hospitals to increase the likelihood of this kind of adverse event, Latent conditions are system. faults chat can be remedied and act within individual hospitals to increase the probability that individuals will ‘make errors, that exrrs will do harm, or both. ‘A disease analogy may clarify some ofthese relation ships. Environmental factors are analogous 10 the ge- netic predispositions of an individual to develop athero- sclerotic heart disease and iss harmful sequelae. At present, these predispositions cannot be altered. Latent condi- tions resemble abnormalities such as hypertension ot hy- percholesterolemia. Like environmental factors, they can lurk unobserved for years, until the atherosclerotic plaque they promoted rupcures and causes a myocardial infarction. Unlike environmental factors, latent condi- sions can-be effectively treated, reducing their-capacity for harm. Some of the most important enviconmental factors pertinent to this case are the increasing subspecialization in medicine (particularly in disciplines in which invasive procedures are an important part of practice), ongoing pressures to reduce hospital staf, the trend to perform invasive procedures in hospitals on a shorestay basis, and the unremitting efforts of hospitals 10 reduce lengths of stay. These forces act on all hospitals to re- duce the likelihood thar an individual patient will be surrounded by physicians and nurses who know her well, understand why she is hospitalized, and actively coordinate planned tests and treatments. They act syn- cxpistically to increase the probability that the wrong patient will undergo an invasive procedure. COMMUNICATION, TEAMWORK, AND THE CULTURE OF Low Exeectarions ‘The most important latent conditions in this case include failures of communication, teamwork, and iden- tity verification. Pethaps the most striking feature of this case—one that will be familiar to all clinicians who have worked in large hospitale—is the ftighteningly poot communication it exemplifies. Physicians failed to com- smunicate with nurses, attendings filed co communicate with residents and fellows, staff from one unit fled to communicate with those fom others, and no one lis- 4 Joe 200] ol fol Mee Vlae 136+ Nurer 1]ACADEMIA AND CLINIC | The Wrong Patent tened carefully to the patient. Although no data exist to document how widespread communication failures are, they are probably endemic in lage, complex academic medical centers (23-30), Poorly functioning teams are also a feature of this case. In addition to communicating well, effective eams allocate role responsibilities clearly, train to back up tear members as necessary, monitor team members’ performance, resolve conflicts efficiently, and use well- designed protocols and procedures to assure that com- plex tasks are executed flawlessly (31). Here, che oncol- ey floor team failed in its responsibility to assure that Joan Morris received the care intended for her, and the clecerophysiology laboratory team failed to keep track of whom they were treating and why. How could so many well-trained and well-inten« toned health care professionals ignore so many seem- ingly clear signals char they were subjecting the wrong patient to an invasive procedure? We recognize that ret sospective root-cause analyses are susceptible to hind- sight bias and may overestimate what it was reasonable for participants to know or anticipate in foresight (21). Nevertheless, we suspect that these physicians and nurses had become accustomed to poor communication and teamwork. A “culture of low expectations” devel- oped, in which participants came to expect 2 nomm of faulty and incomplete exchange of information. Nusses had probably observed many instances of patients’ lack- ing information about planned procedures; RNg may have regarded Joan Morris's objections 2s just another such example, Similarly, residents may have grown ac- customed to being unaware ofall the tests or treatments ‘ordered by attendings, and physicians may have ofien filed to fully inform nurses about treatment plans, The combined impact of these experiences probably led these conscientious professionals to discount the numerous ‘warning signals present in this case. The culture of low expectations led each of them to conclude that these red flags signified not unusual, worrisome harbingers bur rather mundane repetitions of the poor communication to which they had become inured. What role did the similarity of the patients’ names ply in causing this adverse event? Patients with similar ‘names present challenges to the best-fanctioning health care systems, In chis case, the similar-sounding names led to errors that exposed long-standing system weak nesses that failed to prevent harm. 00] 6 ne 202 Anette Made Vane 136+ 12 One of the most important defenses against this kind of adverse event was absent: a standardized proto- col to verify patient identity (32). Despite the commu- nication and teamwork failures, che adverse event could hhave been prevented at several different times if such a protocol had been in place and adhered to by cither the electrophysiology laboratory or the oncology floor. Some automated verification systems (For example, bar- coding technology) may help to reduce the likelihood of misidencifications. But the technology still requires 2 protocol tobe effective. A particular team member must be charged with matching the bar code on the patient's identity bracelet to the bar code on the medication, blood product, or invasive procedure schedule. Furthermore, this hospital suffers from an informa- tion system disease that we suspect is common to many large academic medical centers: a patchwork of home- ‘grown information minisystems, few of which interact effectively wich each other; Because-the clecerophysiol- ogy laboritory’s computer system could not connect to other hospital systems, it could not use their data to vetify patient identities, Finally, if Ms. Mortis's medical record had con- tained legible and clear information about why she was in the hospital and what treatments were planned, one of her caregivers might have recognized the misidentif- cation and averted this adverse event. The increasing frequency with which invasive procedures are performed during brief hospital stays encourages less documenca- sion in the patient’s medical record. Caregivers may thus expect lide pertinent clinical information to appear in these patients’ charts and not consider its absence wor- risome, Although these environmental factors and latent conditions were crucial in setting the stage for this event, individual factors undoubtedly also increased the likeli- hood of errors. We do not know all of the seessors chat were operating on each of the individuals in this case, but a few common ones may have been involved. RN; was at the end of her shift on the oncology floor; she may have been in a hurry to leave and pethaps was less attentive ro apparent warning signals than she would have otherwise been, Were other staff affected by this factor o by fatigue? Was the neurosurgery resident or cleetrophysiology fellow exhausted after a night on call 63.35)? Factors that increase the likelihood of individuals ss cry7 making errors can never be completely eliminated. Hu- ‘man performance can be improved but not perfected, Industries chat have reduced serious errors to extremely low levels have done so not by perfecting human perfor- ‘mance but rather by improving the performance charac- teristics of the systems in which the humans work (22, 36, 37). Thus, the inevitable human errors are inter- cepted and prevented from doing herm. As Reason con- cludes, “We cannot change the human condition, but we can change the conditions under which people work” QD), How Can We Avowo THese Errors? First, everyone practicing in complex delivery sys- tem settings should recognize that performing an inva- sive procedure on the wrong patient is an all-too-real possibilty. No large hospieal is immune from the indi- ‘vidual errors or latent condi Yet, it appears that Joan Morris's caregivers did not con- ceive that ic was possible that they had the wrong pa- tient. As clinical teachers, we impress on trainees the importance of consideting the most obscure diagnoses in evaluating individual patients. Similarly, we need to szise our index of euspicion for the possibility that pa- tients are undergoing invasive procedures not intended for them, Furthermore, we believe that open and vigorous dis- cussion is a prerequisite for robust solutions. We were disappointed but not surprised that we could not find a single article in the literature discussing this problem, Given the enviconmental influences that are probably increasing the likelihood of these events, we must com- bat the clinical nunnel vision that subspecialization en- ‘courages. Nursing staff should take particular care t0 familiarize chemselves with short-tay patients and theie treatment plans, No patient should leave a hospital for for a procedure without a signed order and a fully exe- cuted consent form in che medical record. Hospitals should develop specific protocols for communicating vi- tal clinical information when patients must spend time oon inpatient units unfamiliar with their conditions. All units in which invasive proceduves are performed must develop and adhere to routise, standardized procedures for verifying patient identity. ‘We believe that the communication and teamwork failures so prominent in this case are commonplace and aml ons_ present in this case. _ TieWngtaier] ACADEMIA AND CLINIC lie at the root of many preventable adverse outcomes in health care delivery, Remedying such filures is at once out greatest challenge and our best hope for improve- ment. We should, however, resist the temptation to use punishment as an instrument of improvement in this ‘ase, No single error caused this adverse event; there is rho reason to expect that punishing individuals would reduce the likelihood of recurrence, Little research has addressed the relationship be- ‘ween communication or coordination of care and pa- tient outcomes (38-40). We found no proven, effective interventions to improve communication and teamwork in health care delivery. However, a model for us to em- ulate does exist, When the National Aeronautics and Space Administration carefully studied the causes of a plane crashes in the 1970s, it concluded that 70% volved human error rather than irremediable mechanical failure, The most common ecrors related to failed com- munication. and.teamwork-(41).-‘These-findings-led-to the development of a comprehensive set of taining pro- ‘grams known as Crew Resource Management (CRM), which has now been implemented by the U.S. Federal Aviation Administration for all commercial airlines These programs teach crews how to avoid bartiers to effecive communication and how to function well as teams. Evaluation has shown their effectiveness (42), Recent research conducted by one of the developers of CRM has begun to characterize patterns of poor commu- nication and teamwork among surgical and intensive care unit scams (31, 43) In one stady, researchers compared the responses of pilots and surgical eams about several factors imporcant in managing errors. Pilots were much more lUkely to acknowledge the adverse effects of fatigue on theit ‘own performance (6494) than were surgeons (18%) and to ‘agree that junior tam members should be free to question decisions of thei seniors (9796 vs. 55%) (44). Applying CRM to medicine will quite the development, testing, and evaluation of methods to train (and periodically te- ‘tain health care workers ro value effective communication and eamvork, break down communication baits (for ccxample, hierarchies within and berween professions, boundaries berveen departments), and function effectively as ceam members (for example, by repetitive practice of errot management strategies in simulated patient care ‘scenatios) In this case, Joan Momris was mistakenly subjected ‘0 an invasive procedure over her repeated objections. 4 on 2 Ao nal Maou 136+ Nant 1084TY ACADEMIA AND CLINIC |The WengFatie [Even though many individuals made ecrots, none was egregious or causative by itself, Instead, the systemic problems of poor communication, dysfunctional teams, and the absence of meticulously designed and imple- ‘mented identity verification procedures permitted these cerrors to do hatm, Juse as we screen asymptomatic pa- tients for hypertension, all health care systems should assess how well communication, teamwork, and proto- cols are functioning. Just as treating hypertension effec- tively prevents strokes, addressing underlying system ews will greatly increase the likelinood chat the inevi- table errors of individuals will be intercepted and pre- ‘vented from causing harm. ‘From Mount Sinl School of Meine, New Yorlo New Yorks end ‘Unive of California, Sax Francisco, San Francie, Californx. Grant Support: Funding for the Quality Grand Rounds serie i sup- pored by the Calfonis HeakhCare Foundstion ss parc of tz Quality Iniicve- Requests for Single Reprints: Mark R. Chassa, MD, MEP, MPH, Department of Health Policy, Mount Sinai School of Medicine, Box 1077, 1 Gustave L. Lewy Pacey New York, NY 1002946574; ema, markchasin@ mem ae, Appendix table, curent anchor addres, excerpts of patcat ind pro- der inerviews, and exorps of the querion-and-aniwer fein are svisble a winranralecrg. References 1. Resn ME Supon operon rang pan. St Peteburg Tees 11 Jy 199814 2, Sry) Suge misleads eprint cles hopialAisoesHepbc 26 Aspe 199831, 23. 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Finucane, MD Jolns Hopkins Bayview Medial Const Baltimore, MD 21224 38. Kons WA, Drper EA, Wagner DP, Zimmerman JE. An enon of Submision from rider ae welmed. If th quoution sublet he eer name wll be aclnowicdged. Pen include complete aren lng wth page nus en whch te qeotion wi found) done for any eleceae Te dar wean “June 200 Ana eee Matinee 135+Nanker 1 [69