From the Editor

Original Research

Application of Best Practices


A Primer on Cognitive Errors Illustrated Through the Lens of a Neurosurgical Practice
Jeffrey Evan Florman, Lisa Almeder, and Robert Trowbridge

Patient Safety and Quality Improvement Exemplars


Evaluation of Pharmacist- or Nurse-driven Long-acting Insulin Titration Protocol in Adult Primary Care Patients with Type 2 Diabetes
Ruth Manzi, Corinn Martineau, Carmine LaPorta, Mary Muca, Samantha Marrier, Donald Medd, and Jennifer Aronson


Multidisciplinary Protocol for the Management of Violent Patients and Promotion of Workplace Safety in the Intensive Care Unit
Kathryn A. Hess MD; Shawn Taylor RN, BSN; Susan F. Goran RN, MSN; and Gilles L. Fraser PharmD, MCCM

Innovation Highlights


Building a Peer Reviewer Community of Practice
Victoria Hayes MD; Robert Bing-You MD, MEd, MBA; and Wendy Craig PhD


Development of a Certificate in Healthcare Improvement for Inter-Professional Teams
Kathleen M. Fairfield, Hannah R. Martin, Peter W. Bates, Erin M. Graydon-Baker, Mark G. Parker, Jordan S. Peck, Debra A. Rothenberg, Ghassan A. Saleh, Isaac Z. Stickney, John Tooker, Robert L. Trowbridge, and John E. Wennberg

Case Reports


Loperamide toxicity: a case report of turning bowels and twisting points
Katherine Rizzolo, Ryan Best, John E. Erickson, and Tammi Schaeffer


Multifocal Bone Pain, Recurrent Fevers and Anemia in a 15-Year-Old
Anna M. Martens, Catherine Ezzio, Amanda Goddard, and Leah Mallory

Research and Quality Improvement Brief