VentMedic

He did not get the Bachelor's degree in business to maitain a job as an EMT-B but rather to pursue other opportunities with the restaurant business. I believe once you have completed at least a satisfactory level of education in EMS, one can of course then continue higher eduation in whatever benefits their career or interest. However, I feel it is rather odd for someone to put in just a few hundred hours of training into a profession that deals with human lives but will put in several years of education to achieve a degree in something that is totally not related to medicine. While cosgrojo did see a value to education he was not always in agreement a degree is the way to go. Yet, there is probably no disagreement that the Bachelor's will help him in business. Also, many Fortune 500 companies want their mailroom clerks making a poverty level wage to have a minimum of a Bachelor's degree and few if any will put up any argument against that even though there is no cert or license requiring it. Rather, the employer just makes a recommendation. My Associates degree is EMS/Paramedic. My Bachelor's is in Cardiopulmonary and my Master's degree is in the college of education in Exercise Physiology. Most are related to medicine although some would argue the education classes in my Master's are a waste for EMS since only a few hours of training are needed to be certed as an EMS instructor. herbie, I do owe you an apology since I realize you probably did not know what my statements about Collier County meant. However, if you do a search for Collier County on this forum you will find several discussions that will get you up to speed. EMS has put much emphasis on skills and hours of training to where they have come to believe the education part can be side stepped. Thus when you have continued to measure EMS training in "hours" and emphasized "skills", I can see how you may actually not see a problem with this because that is the norm for you and much of EMS. Medical Directors should look at more than just a "skill" to measure his/her employees' competency. But then this is what Doctor Tobin did in Collier County and was greatly criticized by the FFs who thought is was just horrible that they had to know the hows and whys of their "ALS skills". I have posted that paragraph again now that you have a little history on Collier County. herbie, it is obvious that I or no one here will ever convince you that even the Associates degree will ever be of benefit to EMS. You seem firmly rooted in the skills aspect of the job. While they are important, knowing the hows and whys would be even better. Now back to the levels, if you were to read some of the posts on the forums that cater primarily to EMT-Bs, you might see where 120 hours of training is NOT enough and the AEMT might be some improvement although probably not near enough.

Almost all the state technical colleges and state communities colleges that have a nursing and/or allied health program have cheap CEUs. For online: Florida Medical Education Services http://www.fmes.net/ They are reasonable and report directly to CEBROKER which you will become familar with when you get a professional license. http://www.cebroker.com

Actually the major differences are college level A&P from college level reading books, pharmacology and pathophysiology. Believe it or not even the general education classes like math and some writing class are of importance. Becoming more literate and being introduced to various journals will help one read real medical journals and not just look at the pretty pictures in JEMS. Also, with a degree, you have bargaining power which you don't with tech school hours of training. But then again, those who have not acheived higher education may not understand what they are missing. At least cosgrojo posed well written posts for his argument but then he did have a Bachelor's degree. However, it is kinda ironic that one goes the extra time in class to get a Bachelor's degree to run a restaurant and not for saving lives. But, he has chosen to follow his true passion in the restaurant business. Those who have a passion for saving lives should take the same ambition and be prepared for a career and not just a job. Other professions teach their health care practitioners when, what and why before the "skills" are ever introduced. If not, you end up with a FAIL as in what happened in Collier County. They argued for the "skill" of giving a med but when asked to apply it in theory on a test that didn't ask simpe "tech" questions, they were clueless. But then they are not the only ones as there are those who still believe "lido numbs the heart". So yes they may be able to do the "skill" of pushing a med or even intubating but do they really know when and why or why not?

At a well organized community college program, you can get more clinical time than with a medic mill. As well, you can still work a few hours as an EMT. Other Allied Health Care and nursing students often have families and work full time besides carrying a full load. At least if one takes the right prerequisites and doesn't full around with the "Overview of the Body for Paramedics" mess for A&P, one can transfer easily among the differe majors. However, I would never recommend someone to take the Associates degree that is being offered now by the medic mills as they are a waste with credits that tranfer to nowhere. It is also better to work as an EMT while you are learning so you actually know more about patient care. The 120 hours of firstaid does not prepare one at all for the mostly medical patients someone will see on IFTs. The sooner he can get finished with the degree, the soon he can get his name in the hat for a FF job. In Florida it is almost not worth one's time to apply to a FD if you are not a Paramedic. If you were to have a degree that might even give you an advantage since the majority of the 1000 FD applicants have a Paramedic cert from a medic mill but have never worked as either an EMT or Paramedic. Most of will continue their food service job at Burger King or mowing lawns for several years while applying every year to a few FDs rather than work on an ambulance.

That all depends on what state you are in. Florida is getting a little more strict with their CNA cert but some states have already raised their requirements for hours and continuing education. Of course, the CNA programs offered at FL's community colleges and state tech schools are more hours because a few expect A&P to be included. The PCT in Florida is about 600 hours or 6 months at some places. They do offer the phlebotomy and EKG with it.

I agree with Dustdevil. Florida has an abundance of Paramedics waiting for a FD position. With nursing you would at least have a decent job with flexibility. RNs in Florida can also challenge the Paramedic test which many who have wanted to join the FD for the benefits have done.

I guess in all fairness I need to add I am not suggesting these FFs be severely punished. Rather, I think this should be looked at as a safety issue which the FD may have taken for granted before now and did not see a reason to make a big issue out of how get drive the trucks out of the station. Now they have had to put what should have been known all along into writing. Most FFs know they have huge blind spots in many areas of the truck which is why most are cautious when pulling out, backing up and taking corners. To blame the guy who got run over in this situation is not valid. This was on the FFs home turf and not some random street setting to which they had less control over. If you can not start safety at home, the "public safety" in your job title means very little. Thus, there are bigger issues here rather than just criticizing the guy's lifestyle. Excuses and blaming the patient won't always work to get someone off when they fail to follow a few basic safety guidelines and especially those they preach to the public. It is also tragic that the FF driving the truck will have this in his memory. That is unless he has justified this incident in his mind that this guy was worthless and he did the community a favor. I will however give him the benefit of the doubt and not believe the comments at the end of the news article from anonymous people who claim to be his fire department buddies. But, that also means some shouldn't take the words of anonymous witnesses that this guy was suicidal especially if they had a cell phone in their hands and watched the events unfold. Our job is not to judge a patient's worth by the way they have chosen to live their life. Rather, those who are in EMS and Public Safety should do everything possible to see the patient is directed to the help they need if they fall onto your driveway regardless of the reason. If they have just stumbled and don't need your help, you can still get them pointed in a safe direction until they are out of harm's way from your trucks.

Where did you get such reliable information that you are so CERTAIN this guy was committing suicide? But even if he was suicidal, wouldn't he be worthy of being helped? This isn't about the guy's life issues but the fact that these FFs did not check before hauling arse out of their station. This is a very simple fundamental safety issue that this FD preaches at public safety events to the general public. So why the double standard? Again, the FDs in Florida provide EMS. The fire stations are often frequented by people who want their BP check which is what one news article reported this guy to saying was his intent to being there. Between being intoxicated and sick, he may not have be able to move quickly. If these FF were hauling arse, nobody in that shape could have moved that quickly. The guy might also have known he would have been ignored if he just knocked on the front door because he was just a drunk and as a few have implied or actually stated in the comments section of that newspaper. Thus, as the paper also stated he know which bay the "paramedic" truck was in. The ladder truck could possibly have done more damage. He also didn't make the call so he had no idea when the truck would be exiting or if it even would be anytime soon. The witnesses who apparently made the statements that they saw him lay in front of the door made no effort to warn the FFs. They may have even made the call to 911 but failed to state the exact location so they have their own issues to deal with. They made an assumption without knowing his intent or seeing how bad he was injured and/or ill. Just going on hearsay from anonymous witnesses who failed to warn the FFs or at least place another call to 911 with the patient's location does not mean this patient was suicidal. They just watched. They didn't even have to get close to the guy. They could just dial 911 on their cell phone. You have NO proof this guy wanted to kill himself with a fire truck. Again, there were many more reliable ways of killing himself very close to that station without waiting for the possibility of the Paramedics getting a call anytime soon. If we used your logic, there should be a warning campaign to discourage ANYBODY from ever going to a fire station for any type of help. As well, since the fire stations are supposedly safe havens to drop off an unwanted baby, that also should be discouraged as someone might leave the baby at the wrong door in hopes someone would see it since the front door is not always used after sunset.

The guy did not jump out in front of a moving fire truck. He didn't have a phone to tell the FFs to run over him. There's a seriously busy highway nearby with fast moving traffic that he could have walked out on. Instead, the guy was at a big building known to house people who could provide some first aid. Regardless of his intent or his chosen lifestyle, the FFs failed to look. This could have been an elderly person just as easily who passed out while trying to get medical help. Just because the patient has alcohol on board does not make him any less in need of help than the suited businessman who could also pass out while having a heart attack at that door. Next time you see a person wanting to jump from a building or bridge, just push them if they don't meet your idea of worthiness for care or a reason to approach with caution. You could then use the same arguments of defense that they asked for it.

Actually, you pointed out what I missed. If there was no immediate follow up CXR after intubation at the original hospital, there is little to say but the intubation could have caused the lung collapse. Not knowing the full extent of the baby's medical history and anomalies, this intubation may only prolong the inevitable and/or the baby may have to be trached and pegged. That is not always a good thing especially in remote areas that lack in home care. Quite possibily without knowing the intent of the original hospital/doctor and if they were just waiting for the family to come to grips with realty, this may now have caused the baby and family to be put through several more weeks of torture. Again, not enough information about the prognosis of this baby.

It would depend on the type of PNA as to whether antibiotics would be warranted. When you say collapsed lung, do you mean atelectasis or a pneumothorax? Did you point out absent breath sounds on the collapsed side or what this already know and they were using CPAP to re-exapand the lung? Did you note the PMI which should have been done as part of your assessment? Did you transport the baby on CPAP? If so, what machine did you use? Is it possible that if the collapse was a pneumothorax, could you have caused it in transti? Heart sounds? Did the baby still have a PDA and was your pulse ox pre or post ductal? Congenital heart defects? What was the prognosis of the baby? Any other anomalies? Was this baby even considered viable at birth due to other defects? Did the doctor inform the parents of the chances of severe deficits and was trying to coax them toward a non aggressive route? We often see family members who can not deal with the word "futile" and will often request an ambulance privately to move their loved one to the ED of another hospital since no other doctors will accept a transfer. Often the other hospital will tell them the same thing. You have not provided enough information about the baby for any conclusions to be drawn. However, I will tell you a little story about one of the reasons why Paramedic students are no longer allowed in our neonatal ICU. We had a little baby that looked cute and normal but had anomalies that were not compatible with life. The decision was made with the parents involved to terminate life support. The Paramedic student went to the parents and told them we committed murder by not giving the baby a chance. Thus, if you came in with a "save the world" attitude, you would probably get more than a cold reception. Sometimes nature will still win.

Could it be possible the FD thought safety was a commonsense thing? I remember when I was first starting out at both the FD and the ambulance service, my mentors told me about the blind spot in front of the truck. Unfortunately my EVOC training did not make any mention of that. Maybe that should be emphasized. This isn't the first time an ambulance or police car has ran over the patient or a member of the public.

Yes, Arnold Palmer has its own ambulance which is staffed by RNs and RRTs. There might have been an EMT driving the ambulance. Florida statutes and the AAP (American Academy of Pedicatrics) are pretty specific when it comes to the qualifications of those who transport neonates and children. Pediatric education is lacking greatly in the current Paramedic curriculum. http://orlandohealth.com/arnoldpalmerhospital/OurMedicalSpecialties/PediatricCriticalCareTransport.aspx?pid=4943 If EMTs or Paramedics do work in a hospital it is often under another title as the prehospital cert is just that...a prehosptial cert. They will work under whatever job description the hospital gives them.

That makes it okay for the FFs to run over him and ignor safety? Are you saying that because he was where he was regardless of intent, he deserved what he got? Are you in agreement with all of the other "FFs" posting the comments at the end of the original article and that is why you are making this "he was sucidal argument? What's with the double standard? FFs lecture the general public all the time about checking around their vehicles before pulling out of a driveway. That is part of their "public safety" message. Hell I've even seen them go to court to see someone gets a long prison sentence for doing essentially the same thing. Are some FFs now just going through the motions of "public safety" and are only in the FDs for the benefits?

I don't know what points you are missing. I have given many examples of how nursing and other allied health professions encouraged those entering and already in their profession to get a degree long before it was required because they KNEW that was their ultimate goal. They didn't wait for some union to say it was okay or wait for someone to MAKE them get a degree. Most saw the need themselves. Once the educated become the norm or increase in numbers enough to show a difference between the grads from a medic mill and a degree program, those with legislative powers will get the message. Thus, it is up to those in EMS to start controlling their OWN destiny and that of their profession. The other thing, as I have also mentioned many times in this thread, is to raise the educational standards for the instructors and make them true educators. That could within reach more realistically but at this time since there are few with even a 2 year degree, it will take a while to implement that. Once the instructors become educated, they can be role models for education rather than relying on "fish" tales to prove their value in the classroom. Honestly this is not a difficult concept but if those who are providing the patient care fail to see the importance of an A&P class, what hope is there. Unfortunately too many are like you who just want to wait and be made to get a degree instead of taking the initiative yourself to set an example. If you already have a degree as you say, why do you think a mere 2 year degree is so unrealistic? Once there are more educated people to speak for education, the IAFF and private ambulance complanies would be foolish to point out education is a waste if it puts them in a bad light with the tax payers. But, you can just sit back and continue to make excuses so you and the herbies of EMS can complain about the FDs. But, I think this speaks volumes for your stance. You are an EMT and not even a Paramedic but yet you are trying to tell us about a degree as a Paramedic. This would be like a CNA telling an RN that his/her BSN shouldn't be obtained until they are made to get that degree. But, you are not even pursuing the Paramedic or even EMT as a career. After 30 years I still have hope that the Paramedic will become a recognized professional health care provider but that is only if we stop catering to the weakest links and listening to the excuses or blaming someone (or the FD) for our failures in EMS. I have been around to see first hand the many changes in medicine and that includes the many professions which are a lot younger than EMS. Medicine is not fantasy. It is a very much a reality which is based in the sciences. If a profession doesn't understand a few simple sciences, it becomes stagnated. That being said, thank you for the compliments and good luck with the restaurant. I wouldn't mind having a wine bar and bistro for my retirement hobby. But, I am not oblivious to the fact it would take considerable education and dedication just as EMS should.

Now for personal attacks... You are the one who has stated you do not have a degree because it is not required. I have not used the words "undereducated fool" in any of my posts when speaking of you. Those are your words and if that is how you think of yourself, you might consider getting at least a 2 year degree. Having the letters of a degree behind your name is not a bad thing and should not be viewed so negatively. Do you care to point out the spelling mistakes in post #94? Those are abbreviations for the associations and not misspelled words. In the other post I used Dustdevil's spelling for ass which is arse. Could it be others agree that education is important and one shouldn't wait to be told or made to get it if they want a better understanding of medicine to provide quality care to their patients? Of course it would be nice to have the 2 year degree as a requirement for Paramedics.

You tell them you want to be a Registered Nurse. If you tell them you want to be an EMT, you may compromise your chances. Ask them about tuition reimbursement and show them how eager you are to start the prerequisites for nursing. EMT and LVN are not beneficial to hospitals. The hospital will be looking for an employee that is planning on sticking around and advancing. Even though there is an abundance of CNAs, turnover and new hires are expensive when you including hospital orientation and employee physicals.

The major difference between EMS and other allied health professionals is EMS believes it is so different and forgets it is part of medicine. For the RNs and RTs, there were a few hold outs but the majority of RNs and RTs already had their degrees long before the 2 year degree became mandatory or even before they had licensure in their State. FL and CA just got RT licensure in 1986. The RRT just established their 2 year degree mandate and many now have 4 year degrees. Exercise Physiologists have a Master's degree and have license in only one or two states. But, eventually that will change. Athletic Trainers with a 4 year degree do have licensure but have been around a little longer. Do you see how education plays a role in the career you have chosen? Why put the Paramedic at the far end of nowhere with just a tech cert when it deals with patients' lives? Many RNs also now have 4 year degrees. The majority did not have to be told they needed more education. They sought it themselves. That is part of being a good clinician and professional. The one advantage of working in a hospital is you get to mingle with other degreed clinicians. You also get to see the differences of those with a tech menatlity and those who realize they need more education since medicine is ever changing. EMS has alienated itself to where it does not relate to the world of medicine. The "oh we are so different" crap has seriously played a role in warping attitudes against education. Since you, who tries to say you are pro education but have not made any attempt to get a degree, you do not represent those who are pushing for higher standards. In fact, you are part of those holding it back. You spout off one way but state "make me" or offer every excuse not to get an education until you are forced. It is a mere 2 year degree. No one is saying you must even get a Bachelor's degree. What is so difficult about taking a couple of A&P classes and a few additional classes? Why don't you set an example instead just using "EMS" as an excuse not to get a degree? Maybe if you actually got the degree and saw what you are missing, you might be a better pro education spokesperson or at least have a little credibility when you do try to talk about it. 46young should do the same. Since you and herbie are hung up on saying the RNs did not want to get educated, let me given you an example of how you are not correct. In Dade (Miami) and Broward(Ft. Lauderdale) counties, there are 2 community colleges (2 year) that offer the nursing program. Miami-Dade Community College Broward Community College There are at least five major 4 year colleges that offer the program and all have a waiting list. University of Miami FIU FAU Barry University St. Thomas University Nurses are already preparing themselves for the future. If nursing students thought a BSN was a waste of time, they would just wait for an opening in the community college. The other programs are very expensive but most are willing to do what it takes to get a good education and secure a future. But then, that is also what every parent wants for their child also.

Welfare checks, maybe but... There is also nothing in the Paramedic curriculum that would prepare a Paramedic to do what RNs do in home care. When was the last time you staged a wound and applied treatment? What do you know about insulin and diabetes teaching? Nutrition? Tube feedings? Various vacuscular access devices for the long term? Chemo? Stoma care? Various ostomies? Evaluated BP medication effectiveness? Administered all the typical medications many, many times to be familiar with them? Did family education for all of the above procedures? To be effective, one should have enough knowledge and experience where all issues involving long term patient care should come easily for the practitioner. For the CCEMT-P, some ambulance services hand out those letters after a two hour inservice. They may even call them that so the truck can be a CCT but due to protocol restrictions they may not have any more skills or knowledge than a regular 911 ALS truck. Some Paramedics, such as in FL, can have an expanded scope to do IABP and ventilators. However, again, the training/education will vary from 2 hours to 2 weeks. And yes, some doctors have refused to let some Paramedics take the patient unless a nurse went with them when they appeared clueless or overwhelmed by a critical patient. We have also had some very back adverse outcomes from Paramedics transporting patients that were way out of their expertise. Unfortunately the Paramedics didn't understand enough to ask questions or what even what questions to ask. The UMBC CCEMTP is a very basic overview of a few critical care concepts. In two weeks it is very difficult to teach one to be a competent critical care clinician. Several RNs and RRTs have taken the program only to be disappointed in the material but most already had critical care experience and found it to be very basic knowledge. For the Paramedic, it is a decent program but should NOT be taken as an end all or even a good beginning for all there is to know about critical care medicine. Too many have come away from the UMBC class thinking they know everything there is to know and that leads to very bad things for the patient they are assigned the responsibility of. There are only about 5 states that do recognize the CC-P/CICP/CCEMT-P credential in their list of levels. I believe Ohio has a decent setup for their CICP but less than 100 hours of training is required. That pales in comparison to the training other practitioners get for critical care even without the experience. If you look at the degree of the RT, it is essentially an introduction to critcal care medicine and even at that it barely scratches the surface for all one can experience working an ICU. The Canadian Flight/Critical Care Parmedic program is very impressive. Their training is adequate enough to where nurses do not need to accompany them. But, it is built off of an already impressive education foundation. U.S. Flight Paramedics can also have an expanded scope and often do get a decent amount of education and additional skills from their employer. However, the ideal candidate should have at the very least college level A&P. Pathophysiololgy and Pharmacology would also be a big plus. As it is now, an RN is usually paired with the Paramedic if they do CC IFT. It is even difficult for CCT and Flight RNs to keep up with all the advances in Critical Care medicine unless they are hospital based or continue to work in an ICU on their off days. Paramedics do not have that opportunity nor to they have the base education required to fully grasp all the critical care concepts if they graduated from a Paramedic program that just did the minimum "hours of training". Just learning a few "tech skills" to be a knobologist for the IV pumps and the ventilators are not sufficient to manage an intensive care patient. Unfortunately, those that have gotten a CCEMT-P patch from their employers with little training rely on speed to get from point A to point B if taking a nurse is not an option or they bluff enough to make people think they are well qualified. There are of course exceptions. Rid has explained his program for CCT and it appears to be quality.

I don't remember seeing a link to the new levels so here it is. http://www.nhtsa.gov/staticfiles/DOT/NHTSA/ems/811077a.pdf Here's a good site for some info: http://www.ems.gov/ National Association of EMS Educators http://www.naemse.org/ National Association of EMS State Officials http://www.nasemsd.org/ http://www.nasemsd.org/EMSEducationImplementationPlanning/index.asp National Association of EMS Physicians http://www.naemsp.org/ The NAEMSP has a newsletter and a journal (Prehospital Emergency Care Journal) , both of which are great reading material. http://www.naemsp.org/publications.html

EMS also provides inhouse education especially if you work for county, city EMS or a FD. As well many private services also offer their own CEUs. And, don't confuse a union with professional associations. They are NOT the same. We also have medic mills that offer 1 1/2 year medic programs. They meet one night a week and stretch out the "hours" of training. Our most famous medic mill also offers an Associates degree which transfers to nowhere. I believe NH still requires only 1000 "hours of training" to be a Paramedic just like many of the other 48 states. For the teacher's salary: NOTE the work AVERAGE. Go back to that post and look at the word "maximum" and the classification. It is not an appropriate comparison... your numbers are useless. Based on your entry level EMT base pay of 12.41, with a regular 40 hour work week that is $25,812.80.

More people are not run over because other FFs do practice what they preach to the public when it comes to vehicle safety. They don't wait for their fire trucks to kill a lot of at their front door before they implement commonsense rules. Now if only the excessive speed issues, L&S and running 3-4 types of vehicles to every EMS scene could also be addressed, Florida and California might be a little safer for the general public.

It comes from being nearly as old as spenac to gain almost as much wisdom.

If she goes to the hospitals and tells of her plans to be a nurse, they will welcome her. In the meantime they may provide more training for different positions within the hospital with the CNA cert or even get the PCT. There's also OR and Ortho tech which can be done OJT with the CNA cert in some places which she is going through RN school which most hospitals will pay for much of the nursing program.

I just happen to have a couple different credentials, education and over 30 years of experience both in and out of the hospital. I am on a couple of state committees for education. I am also an educator but now find that teaching nurses and RTs more rewarding as they know they the importance of education. Nothing happens overnight but getting an education is less ridiculous than getting a significant pay increase handed to you for doing nothing to improve patient care and safety. Bitter OLD TIME RNs who are jealous of the new BSNs coming in with fresh idesas. These RNs could have transferred to a different department or hospital easily if the working conditions were so horrible. Next time you talk to them, tell them to retire or find a job outside of patient care. If they are this bitter, they are useless to the patients as they are wasting more time on their own attitudes than doing their nursing duties. Regardless of how hard the job is, good nurses will still do what is best for the patient even if that means getting an education. The LVNs did it. Not all "old time" RNs hate change. In fact most do welcome it. Nursing is not easy and those that welcome change often do see the benefits in their job or at least understand it better. We still have Paramedics who push meds just because they can without understanding them or those who hold a Parmedic card just because they want to join the FD and have absolutely not understanding of medicine or patient care. They just want the money and the benefits. The 3 month wonder schools are churning out half-arsed Paramedics who thought Third watch was cool. Two years of actual education might give one a chance to ponder their decision and to grow up a little when they realize there is patient care responsiblity as part of the job. No, there are many BSNs working in patient care. In fact, most of our new hires are BSNs. It seems to have become something that is expected especially if you do have plans to work a specialty such as one of the ICUs, Flight, CCT, OR, transplant, organ procurement etc. But, most of them see a value to just education where ever they world as they are literate and enter with more maturity after spending 4 years in college accepting the responsibility that comes with it. This is my world every day regardless if it is on a helicopter or in a hospital. I see first hand the importance of education. Of course if you want to hear all negative comments about education you can always find someone willing to complain. However, they made the choice to be and to stay in that profession and where they are. The statement I made in bold is used by almost every profession when they are petitioning for higher education or higher reimbursement from insurances. It is also used by many health care professionals when petitioning again Medicare cuts for home care regardless of what benefit it might be to the provider. Look at the collaborative statements on the NP and PA websites about reducing the load in EDs. Look at what they also are doing in their professions to raise their education so they can petition for change to provide patient care and safety.