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Wild Iris Medical Education is approved as a provider of nursing continuing education by the Florida Department of Health, Division of Quality Assurance, Board of Nursing. Acknowledging that errors happen, learning from them, and working to prevent future errors represents a major change in the culture of healthcare—a shift from blame and punishment to analysis of the root causes of errors and the creation of strategies to improve.
An error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
An adverse event is an injury caused by medical management rather than the underlying condition of the patient. The Joint Commission defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Near misses are potential adverse events, errors that could have caused harm but did not, either by chance or because something or someone in the system intervened. Research on why humans make errors (Reason, 1990) has identified two types of errors: active and latent. Latent errors are present but hidden and may go unnoticed for a long time with no ill effect.
A root cause is an action, deficiency, or decision that if corrected, eliminated, or avoided will eliminate the undesirable consequence.
A decade and a half has passed since the IOM published To Err Is Human: Building a Safer Health System. In 2013, the Journal of Patient Safety reported that between 210,000 and 440,000 patients each year who enter a hospital experience some type of preventable harm that contributes eventually to their death, making medical errors the third-leading cause of death in America behind heart disease (the first) and cancer (the second). A recent study of medical malpractice claims showed that slightly more than half (52.5%) of the paid claims related to outpatient care. Medical errors add substantially to the direct costs of healthcare and to the loss of income.
It is not uncommon for healthcare facilities to take cost-containment measures that reduce staffing, particularly RN staffing.
Errors can be placed into five general categories: surgical, diagnostic, medication, devices and equipment, and systems failures (including healthcare-associated infections, falls, and healthcare technology). Surgical errors (or surgical adverse events) account for a high percentage of all adverse events. The Joint Commission found that robotic surgery, a relatively new technological procedure, resulted in an increase in surgery-related sentinel events from 2006 to 2013. The Joint Commission estimates the death toll from diagnostic errors at 40,000 to 80,000 per year, with 40,500 preventable deaths arising in the ICU alone. Although delayed or inaccurate diagnoses are often attributed to physician error, members of the healthcare team can and do contribute to delayed or inaccurate diagnoses due to information gaps and communication problems. Most diagnostic errors occur in primary care settings and most frequently in the testing phase (failure to order, faulty interpretation of results, missed follow-up and tracking) (Joszt, 2013). Other errors were attributed to failure to make referrals and patient-related issues such as inaccurate medical histories (Wood, 2014).
The most common cognitive error that clinicians make is the premature closure of the diagnostic process, where common benign diagnoses are made for patients with uncommon serious disease, signaling a need to broaden differential diagnosis.
Sentinel event statistics compiled by the Joint Commission from 2004 to 2013 show that one of the most frequently reported events is delay in treatment. Diagnostic errors increase costs due to the need for hospital readmission that could have been avoided if the correct diagnosis had been made. Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.
In a study conducted by the Economic Cycle Research Institute (ECRI) patient safety organization, it was found that the phase of the medication process in which the highest number of medication errors occurred was during the administration phase, and more than a third involved intravenous errors (Oh, 2012a).
In addition, movement of a patient from one setting to another and staff fatigue related to working consecutive shifts contribute to these adverse events (JC, 2014c). Design flaws, misuse, and malfunction of medical devices and equipment are all common causes of medical errors. Failure of physicians, nurses, and other caregivers to practice basic hand hygiene helps spread bacteria, some of which are antibiotic-resistant and can prove life-threatening.
Risk factors associated with falling are clinically identified as either intrinsic or extrinsic.
The Institute of Medicine (IOM) has evaluated safety concerns and identified actions that can be taken to lessen safety risks linked with health IT. While adoption of EHR systems offers to provide substantial benefits, there are serious unintended consequences that have emerged from their implementation.
Many providers find that EHRs decrease efficiency and add hours to their workday due to non-user-friendly interfaces and difficult navigation. CPOE can help hospitals reduce ADEs, but only about one third of hospitals have a CPOE system and less than half use barcode medicine administration (BCMA) (Halvorson, 2011).
People age 65 years and older consume more prescription and over-the-counter (OTC) medications than any other age group. The older adult population (ages 65 and older) receives more than 50% of all prescription medication, and most who engage in the healthcare system take 6 to 8 medications (polypharmacy). The risk for an adverse drug event is 15% with two medications, 58% with five, and 82% with seven or more medications. Visual, hearing, or cognitive problems may lead to misunderstanding of instructions or failure to question an incorrect or unfamiliar drug. Prescribing physicians need to consider the slowed metabolism and excretion of drugs in older adult patients—not only the choice of drugs but also the dosage and timing of administration. The potential for ADEs is higher in the pediatric population than that found in hospitalized adult patients. Intensive care units (ICUs) host the sickest patients whose conditions require extraordinarily complex care. The complexity of care in the ICU can lead to life-threatening, sometimes fatal, tubing misconnections, infections, and other complications. Oversight of healthcare quality in the United States is accomplished through both professionally based accrediting bodies in the private sector and through federal and state regulatory agencies. The Joint Commission is an independent not-for-profit agency whose mission is to continuously improve the safety and quality of care provided to the public. Although accredited facilities are expected to identify and respond appropriately to all sentinel events, but not to report them, if the Joint Commission becomes aware of an event, facilities are required to submit the findings of their root cause analyses and corrective action plans. The Joint Commission has issued mandatory goals and recommendations to improve patient safety. The Accreditation Association for Ambulatory Health Care was founded in 1999 by the AAAHC Institute for Quality Improvement, which offers ambulatory healthcare organizations opportunities to learn about and become involved in performance measurement, benchmarking, and quality improvement. Ambulatory care organizations are offered accreditation by AAAHC to demonstrate that the organization takes part in ongoing self-evaluation, peer review, and education to continuously improve its care and services. Have a system for informing a patient or designee pursuant to state law that the patient was the subject of an adverse event. Have an incident reporting system to report adverse incidents to the risk manager or designee within 3 business days after their occurrence. Licensed facilities in Florida are required to submit two types of reports to AHCA: Code 15 reports and annual reports.
Changes in organizational culture, involvement of leadership, education of providers, development of patient safety committees, adoption of safe protocols and procedures, and use of technology are all essential strategies healthcare facilities must consider in their efforts to reduce medical errors.
The mistaken attitude in healthcare that errors are solely the fault of individual practitioners has proven a major barrier to reporting.
A challenge exists in distinguishing between a system that might cause errors, human error that might result in a bad outcome, and reckless behavior that intentionally puts lives or organizations at risk.
A just culture acknowledges that competent professionals make mistakes and recognizes that competent professionals may develop unhealthy norms such as shortcuts and routine rule violations, but has zero tolerance for reckless behavior.
A surgical checklist is an algorithmic listing of actions to be taken in any given clinical situation intended to make everyone aware that others expect these things to be done. Has the patient’s name, procedure, and where the incision will be made been confirmed? For each of the pathways, there are strategies recommended to prevent adverse drug reactions.
There are many facilities that have instituted the practice of medication reconciliation at all transitions in care to prevent adverse drug events. Use different lettering and other strategies in order to reduce confusion between medications that look alike or sound alike. Provide patients with education to enhance comprehension of instructions for taking medications.
Published studies of ADEs have consistently identified certain classes of medications as particularly serious threats to patient safety. In 2012 the Institute for Healthcare Improvement (IHI) created a how-to guide for the prevention of harm from high-alert medications, recommending three principles of safe system design: 1) design processes to prevent errors and harm, 2) design methods to identify errors and harm when they do occur, and 3) design methods to lessen the harm that may result from the error. Standardize the approach to treatment by developing order sets, preprinted orders, clinical pathways or protocols. Centralize pharmacist- or nurse-run anticoagulation, insulin management, and pain management services.
Include in order sets, protocols, and flow sheets reminders and other information about monitoring parameters.
Utilize protocols allowing for administration of reversal agents without having to contact the physician. The Physician-Patient Alliance for Health & Safety (PPAHS) reported that there is cause for concern in patients using patient-controlled analgesia (PCA), and there is a great lack of consistency in safety procedures followed by hospitals across the country. Many health professionals work or consult in non-healthcare settings such as adult daycare, summer camps, schools, group homes, board-and-care facilities, and jails.
The council’s recommendations for the handling of medications (including OTC medications) in these settings include proper storage, written policies and procedures, limitations on the type of medications stored by the organization, training programs, safeguards to prevent theft of controlled medications, and reporting and evaluation of medical errors. An analysis of research and recommendations for preventing misconnections suggests that equipment redesign to make enteral and IV systems incompatible is the most effective way to reduce misconnection errors (Simmons et al., 2011). Connectors manufactured according to the new specifications are entering the workplace, and temporary adaptors are being introduced to connect the old tubing with the new tubing.
Review currently used systems to assess practices with the potential for misconnection, including nonstandard, rigged work-arounds (for example, Luer adapters).
Instruct nonclinical staff and visitors not to reconnect lines but to seek clinical assistance instead. When making a reconnection, routinely trace lines back to their origins and ensure that they are secure. On arriving at a new setting or as part of a hand-off process, recheck connections and trace all tubes.

Package together all parts needed for enteral feeding and reduce availability of additional adapters and connectors to minimize availability of dissimilar tubes or catheters that might be improperly connected. Identify and confirm the solution’s label because a three-in-one parenteral nutrition solution can appear similar to an enteral nutrition formulation bag.
Identify and minimize conditions and practices that may contribute to healthcare worker fatigue and take appropriate action. The FDA regulates devices that support or sustain human life, are of substantial importance in preventing impairment of human health, or present a potential unreasonable risk of illness or injury by using a process of scientific and regulatory review to evaluate safety and effectiveness. The medical device and equipment user (physician, nurse, therapist, technologist, patient, and other service personnel) is the human factor that must be taken into consideration when a new device is being designed in order for it to be operated correctly and safely. Administer antimicrobial prophylaxis in accordance with evidence-based standards and guidelines. Avoid hair removal at the operative site unless it will interfere with the operation; do not use razors. Use appropriate antiseptic agent and technique for skin preparation in the period prior to surgery and immediately before the placement of surgical drapes. Keep OR doors closed during surgery except as needed for passage of equipment, personnel, and the patient. Re-dose antibiotic at the 3-hour interval in procedures with a duration greater than 3 hours.
Use at least a 50% fraction of inspired oxygen intraoperatively and immediately postoperatively in select procedure(s). Use maximal sterile barrier precautions (mask, cap, gown, sterile gloves, and sterile full body drape).
Scrub the access port or hub immediately prior to each use with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol). Avoid steel needles when administering fluids and medications that might cause tissue necrosis if extravasation occurs.
If the duration of intravascular therapy is likely to be more than six days, a midline catheter or PICC is preferred to a short peripheral catheter. Evaluate the catheter insertion site daily and remove peripheral venous catheters if signs of phlebitis develop. For patients with chronic renal failure, a fistula or graft instead of a CVC for permanent access for dialysis should be used.
When adherence to aseptic technique cannot be ensured, such as during a medical emergency, the catheter should be replaced as soon as possible (within 48 hours). Systemic antimicrobial prophylaxis before insertion or during use of an intravascular catheter is not routinely recommended to prevent catheter colonization or CRBSI. Implement a laboratory-based alert system for immediate notification of positive test results.
Educate about CDI: healthcare personnel, housekeeping, administration, patients, and families. Place patients with a MDRO infection in a private room or share a room with others who have the same infection.
Clean and disinfect all patient care items, equipment, and room surfaces every day; utilize a checklist to ensure compliance. Many hospitals are reporting significant reductions in ventilator-acquired pneumonia (VAP) in critical care units. Preventing falls begins with assessment of the patient using one of the several tools available, such as the Morse Fall Scale. Use safe transfer and handling techniques, utilizing gait belt or assistive devices if needed. Many errors have been demonstrated to arise from the lack of adequate or accurate communication. Documentation must be credible and timely and must accurately reflect the patient’s condition as well as the care given. It is necessary to consider the possibility of malpractice lawsuits and how best to avoid potential legal liability. Do not document what someone else said, heard, felt, or smelled unless it is pertinent, and if so, place it in quotation marks. Research indicates that poor communication is a root cause in more than half of all sentinel events. One increasingly popular communication tool is the SBAR format: Situation (S), Background (B), Assessment (A), and Recommendation (R).
To counter errors and safeguard patients, changes must continue to be made in how the workforce is deployed, how work processes are designed, and to leadership, management, and the culture of healthcare organizations. The legal duty of care for acupuncturists is covered including negligence, malpractice, and informed consent. Met requirements and was one of the only companies that actually sent you the information via mail if asked. Great review of basic safety info and minimum competence standards - you can never practice fundamentals too often.
The legal facts and the precautions help me to stay up to date with the reality of practicing Acupuncture. Learn how to diagnose and treat many types of pain, headaches, insomnia, fear, jaundice, skin infections, rebellious Qi and nocturnal emissions with herbal medicine. For acupuncturists, this course is approved for 15 California acupuncture CEUs (category 1), 15 NCCAOM PDAs (core), 15 Florida CEs (13 general, 2 medical errors), 15 Texas CAEs, 15 CTCMA CEs and 15 CAAA acupuncture continuing education credits. This course has fascinating case studies with clearly written rationales for each herbal formula chosen. Wirth slogging through to appreciate the astuteness and originality of the herbal formulas. I truly enjoy this course with a wide opening variety of unconventional use of herbs and formulas may me think and stimulate my hunger for learning more about herbs and to love even more my profession, very well organized. Good insight to both diagnosis and subtle distinctions of herbs with similar functions and how to use them in combinations. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
In the 1950s medical errors were considered to be the price paid for modern diagnosis and therapy.
In other words, healthcare organizations need to create a culture of safety that views medical errors as opportunities to improve the system. Near misses provide opportunities for developing preventive strategies and actions and should receive the same level of scrutiny as adverse events.
Active errors (human errors) are those that involve individuals who are actually doing a task, and their effects are felt almost immediately. The most common root cause of medical errors is communication problems, which can include unclear lines of authority, inadequate error sharing, or disconnected reporting systems. This landmark report revealed an epidemic of medical errors in the United States, with an estimate of up to 98,000 people dying each year due to mistakes made in hospitals (IOM, 1999).
The study also reported that tens of thousands also die from preventable mistakes made outside hospitals in outpatient settings and the community, including deaths from missed diagnoses or injuries from medication (James, 2013). Most malpractice claims for hospital care are related to surgical errors, whereas most claims for outpatient care are related to missed or late diagnosis. According to a study by the Johns Hopkins University School of Medicine reported in 2012, at least 4,000 surgical errors occur in the United States each year.
Complications were usually due to hemorrhage caused by lacerations and injury to surrounding tissues (JC, 2014a). One patient in every six has personally been affected or has had a family member or friend affected.
It is to be noted that a lot of symptoms patients present with are vague, such as fatigue, resulting in a vague differential diagnosis.
Another source of unnecessary costs is unwarranted treatments given due to a wrong diagnosis (Wood, 2014). Subtle differences in a familiar pattern using a device can affect the speed and accuracy of data entry, and the lack of standardization invites user mistakes.
These include cardiac pacemakers, defibrillators, and deep brain stimulation neurotransmitters to control tremors in people with Parkinson’s disease. According to the CDC, 1 of every 20 hospitalized patients will experience a healthcare-acquired infection. Studies have shown that hospital workers wash their hands as little as 30% of the time that they interact with patients and that physicians tend to be the most resistant to hand hygiene (Hartocollis, 2013). Any patient who has had excessive blood loss may experience postural hypotension, increasing the risk of falling. Intrinsic factors include the characteristics or conditions of a person, which can include vision, gait, and health history. The literature about health IT and patient safety is inconclusive, yet it shows substantial potential hazards for patient safety (IOM, 2012). Currently, there is no regulatory framework to monitor EHR system safety and no agreed-upon design standards. Research shows that BCMA can reduce the rate of potential adverse drug events (ADEs) as much as 50%, but errors can still occur (Poon et al., 2010). Although medications may improve the quality of life and health, they also hold the potential for misuse, overuse, and life-threatening complications. Nearly 17% of hospital admissions are due to an adverse drug event, and the rate increases to 33% in patients 75 years of age and older. Because older adults experience a decrease in total body water and a relative increase in body fat, water-soluble drugs become more concentrated and fat-soluble drugs have a longer half-life.
These patients often have feeding tubes, chest drainage tubes, and central venous catheters, and the most common types of adverse events in the ICU involve these lines, tubes, and drains.
This information can be included in the Joint Commission’s review of sentinel events, helping track national trends and develop strategies for improving patient safety. Hospitals and other organizations will be evaluated by accreditation representatives to see whether these recommendations or acceptable alternative measures are being implemented. It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame. The studies conducted by the institute are designed specifically for ambulatory care environments (AAAHC, 2014). The organization performs on-site surveys by healthcare professionals at least every three years. When the reporting of medical errors focuses on the identification and punishment of individual health professionals, there is a huge disincentive for reporting errors, and this punitive attitude severely limits the reporting of errors.

One popular approach is the Just Culture model developed by David Marx and colleagues (2005), which helps differentiate human error from blameworthy errors. Electronic health records (EHRs) should help reduce medication errors, avoid the need to repeat laboratory tests, and improve continuity of care across the healthcare system. All operating room personnel have a role in ensuring patient safety by verifying the surgical site and pointing out a possible error. Checklists have been responsible for some of the greatest successes of the patient safety era, particularly in improving safety for surgical patients. The Joint Commission and the Institute for Safe Medication Practices (ISMP) have published lists of high-alert medications. Although many of these drugs carry a black box warning (BBW), the FDA’s strongest labeling requirement, one study indicated that some physicians and pharmacists might ignore BBWs in prescribing and dispensing drugs. This is believed to account for a large proportion of adverse events and deaths related to its use. The PPAHS checklist recommends certain steps be taken when initiating, refilling, or reprogramming PCA pumps, and PCA checks to be taken at shift change and hourly. These facilities are usually licensed by the state but often use unlicensed staff members to dispense medications to patients.
However old connectors will remain in use and the potential for misconnections will still exist until existing supplies are depleted (JC, 2014f).
Only clinicians or users knowledgeable about the use of the device should make a reconnection. Educate staff about the labeling or color-coding process in the institution’s enteral feeding system.
This means the design must consider the perceptual abilities associated with sight, hearing, and touch. Preventing these dangerous oversights may have a low-cost, high-yield solution, such as a simple checklist of evidence-based practices in infection control, like handwashing and other fundamental procedures. In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used. It is recommended that assessment for fall risk should be done by nursing for every patient on admission. The MFS requires systematic, reliable assessment of a patient’s fall risk factors upon admission, after a fall, upon change in status, and at discharge or transfer to a new setting. Meticulous medical documentation helps to prevent practice errors and provides a shield against errors arising from miscommunication.
Illegible writing, overuse of abbreviations, and poor transfer of information (both within a department and when a patient transfers to another department) can cause medical errors. Whether it is nurse-to-nurse, nurse-to-physician, or physician-to-physician communication, having a standard framework and proven tools for reporting and sharing information can enable more effective communication. Everyone has a stake in the safety of the healthcare system—healthcare workers as well as the general public. Physicians, nurses, therapists, and other healthcare personnel are members of a team, and it is crucial that these team members work together and communicate effectively.
Critical thinking skills to reduce medical errors is reviewed and safety rules are covered.
Download the course, complete the online quiz and receive immediate acupuncture license credit.
After reviewing the course, take the online quiz and a certificate of completion will be automatically generated for INSTANT credit. However, in the presentation there is often a disc between the presentation, the diagnosis and the herbal formulas.
More deep and fun that my NCCAOM test that one was more for school text book, it was lovely. Wild Iris Medical Education, Inc., provides educational activities that are free from bias. But over the ensuing decades, medical errors have increased to epidemic proportions and currently are the third leading cause of death in the United States. Every person on the healthcare team has a role in making healthcare safer for patients and workers.
Latent errors are errors in system or process design, faulty installation or maintenance of equipment, or ineffective organizational structure. In 2010, the Office of Inspector General for the Department of Health and Human Services reported that more than 180,000 patients enrolled in Medicare alone die in a given year because of poor hospital care (U.S. Medication errors are also common in outpatient malpractice claims, particularly those related to transition from hospital to community-based care (Bishop et al., 2011).
An analysis of data from nearly 200,000 hospital admissions and 176,000 nursing shifts of eight hours each showed that staffing of RNs below target levels was associated with increased mortality (Needleman et al., 2011).
Almost half of pediatricians come upon one or more diagnostic errors every month, and 1 in every 1,000 primary care encounters will cause preventable harm from diagnostic error (JC, 2014b).
This includes delays in medication, lab testing, physical therapy, or any other kind of treatment (Wyatt, 2014). Medications are being delivered via the wrong route, and equipment design leads to making such misconnections. Unfortunately, this universal design allows tubes or catheters with dissimilar function to be connected, with potentially disastrous results.
Poor medical device design and lack of usability testing have also been repeatedly discussed as being key factors in many device-related incidents.
Each year, one third of people over 65 suffer a fall, and one third of these falls cause both fatal and nonfatal injuries. Maternity patients or other patients who have epidural anesthesia are at risk for falls due to decreased lower-body sensation.
In addition, they report the computer comes between the patient and provider and fosters distractions. One obstacle is the upfront cost, which is approximately $1.9 million, with $500,000 per year for maintenance. In addition to prescription medications, older adults purchase 40% of over-the-counter medications, use OTCs three times more, and use herbals twice as much as the younger population. Additionally, while in hospital, 17% of older adults experience an adverse drug event (Bland, 2013).
Critically ill patients receive nearly twice as many medications as patients in general care units, and most medications involve calculations for bolus administration or continuous infusion.
Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Failure to implement the recommendations could result in loss of accreditation and federal funding. In fact, research shows that when the fear of punishment is removed, reporting of errors actually increases. Facilities should carefully select the best system available, adopt best practices for EHR implementation and management, monitor how the health IT system is used, and report any adverse events.
To reduce the risk of wrong-site, wrong-procedure, or wrong-person surgeries, the Joint Commission developed a Universal Protocol (UP) in 2004 requiring compliance by all accredited hospitals, ambulatory care, and office-based surgery facilities (JC, 2014e).
The goal is to ensure the correct medication is provided to a patient at all points of transition within the facility (IHI, 2014a).
According to the National Coordinating Council for Medication Error Reporting and Prevention, medication errors are a significant problem in these settings. Reassessment should be done upon transfer of a patient from one unit to another, with any status change, following a fall, at regular intervals, and with changes in caregivers.
Healthcare professionals must learn and follow their facility’s policies and procedures about charting.
To avoid liability, it is important to be able to explain and justify (based on EBP) the care given by each person if one is subpoenaed.
In the past, patient safety and quality have not been a traditional part of the education of most healthcare workers, but today this is no longer an acceptable reason for not taking an active role in the prevention of negative outcomes for those we care for. Those in leadership roles claim that error reduction is extremely difficult due to the complex nature of healthcare facilities and the fact that patients are very sick. Other factors contributing to misconnections include the routine use of tubes or catheters for unintended purposes, such as using IV extension tubing for epidurals, irrigation, drains, and central lines. In 2013 the Joint Commission reviewed 82 fall-related events resulting in death or permanent loss of function (JC, 2013b). Extrinsic factors involve conditions outside the person, such as environmental hazards and medications.
Another obstacle is resistance by physicians to utilize such tools, instead preferring to rely on practice experience (Leapfrog, 2014).
The most common medication error types in ICU are administering the wrong dose, omission of a dose, wrong administration rate, and wrong administration time (Blumenthal, 2014).
Low health literacy is linked to a higher risk of death and more emergency room visits and hospitalizations. The three principal components of the UP include a pre-procedure verification, site marking, and a time out.
This tool can be used for hand-offs between shifts and between caregivers, as well as for debriefings on internal issues, information on new procedures, and email communication.
It is essential that we all understand the journey every patient makes through the system, recognizing how the system can fail and what can be done to prevent those failures. Our expanding awareness of this issue demands improvement in our understanding of the problem and in finding effective solutions and prevention strategies to make our healthcare system safer. If you prefer to receive your course in the mail, click CONTACT US to have the course content mailed to you. Professor Liao has served as professor of herbology and acupuncture theory at the Academy of Chinese Culture & Health Sciences in Oakland, California.
395–10974, who is responsible for implementation and oversight of the risk management program. Liao has also served as a faculty member at Five Branches University in Santa Cruz, California.

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