Volume 2, Issue 2 (2020) Volume 2, Issue 2 (July 2020)

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

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