The Nurse's Role in Medication Reconciliation - BC Patient Safety ...

The Nurse’s Role
in Medication
Reconciliation
Authors
Chapter 1
Jennifer S. Johnson, R.N., C.M.A., charge nurse, telemetry
unit; Paul Mollo, Pharm.D., director of Pharmacy;
Caryl-Ann Mannino, R.N., O.C.N., director of
Professional Practice and Oncology; Susan Hiza, M.B.A.,
management engineer; and Linda Miller, R.N., M.S.,
C.N.A.A., senior vice president for Nursing, Our Lady of
Lourdes Memorial Hospital, Binghamton, New York
By definition, medication means something that treats the symptoms of
disease and reconciliation means the act of compliance or agreement.
Together these two words, medication reconciliation, represent a
process by which a complete list of each patient’s current medications is
obtained every time the patient enters the health care organization and is
then communicated to subsequent providers in or out of the same health
care organization. The goal of medication reconciliation is to prevent adverse
drug events that could occur by allergic reactions, omissions, substitutions,
and/or duplications. It is a necessary, yet simple, way of assessing what medications
patients are currently taking.
Medication reconciliation is necessary because a patient’s medications can
change at any point in time for any number of reasons (such as a newly diagnosed
disease process, an age-related issue, an acute condition, a worsening
chronic situation, a short-term need for antibiotics, patient altering medication
regimens, or adding nonprescription, herbal, or other products to their
regimen, or elective or emergency surgery) and because those medications can
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The Nurse’s Role in Medication Safety
precipitate one or more allergic reactions, food and drug interactions, and/or drugdrug
interactions. Medication reconciliation is an extremely important process that
needs to take place every time a patient is involved with any health care system.
Therefore, medication reconciliation was clearly an excellent choice when, in
July 2004, Our Lady of Lourdes Memorial Hospital, Inc., Binghamton, New York
(Lourdes Hospital), was asked by Ascension Health Ministries to participate in one
of the eight Priority For Action Teams, whose goal was to have no preventable
deaths by July 1, 2008. Medication reconciliation was one way to achieve that goal.
The Adverse Drug Event (ADE) Priority for Action (PFA) Team selected by
Lourdes Hospital was to be mostly composed of direct patient care nurses from all
departments (from inpatient to outpatient) and management from various clinical
and nonclinical backgrounds, including a pharmacist, a clinical nursing director, a
physician, a management engineer, and the chief nursing officer. During the initial
team meetings, a crystal clear definition of medication reconciliation was agreed
upon so that the medication reconciliation task could be implemented across the
organization. (See the box below for the definition of medication reconciliation as
well as the language for National Patient Safety Goal 8, which pertains to medication
reconciliation.)
Because this particular chapter pertains to the nurse’s role in medication reconciliation,
it is presented in the nursing process format, wherein the nursing assess-
Medication Reconciliation: The process of comparing a patient’s
medication orders (those newly prescribed) with all the medications the
patient takes (previously prescribed as well as self-prescribed, including
over-the-counter products such as herbals and supplements). 1
National Patient Safety Goal 8
Accurately and completely reconcile medications across the continuum of
care.
Requirement 8A: There is a process for comparing the patient’s
current medications with those ordered for the patient while under the
care of the organization.
Requirement 8B: A complete list of the patient’s medications is
communicated to the next provider of service when a patient is
referred or transferred to another setting, service, practitioner, or level
of care within or outside the organization. The complete list of medications
is also provided to the patient on discharge from the facility.
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Chapter 1: The Nurse’s Role in Medication Reconciliation
ment leads to the diagnosis of the problem, the planning of the goals and outcomes
is followed by the implementation of the process, and subsequent evaluation and
measurement dictate the success or failure of the process.
Assessment
Assessment of the issues involved with implementing medication reconciliation by
using a pilot unit
In September 2004, the organization chose the cardiac telemetry unit as a pilot
unit in which to assess and introduce the idea and subsequent use of medication
reconciliation. The first test of change for the new process included the following
participants:
• One nurse (who was a member of the ADE team)
• One physician (who admitted a high number of patients to the pilot unit and
would be amenable to change)
• One patient (who was typical of the patient population and had an accurate list
of current medications)
Prior to enacting the new process on the pilot unit, medication reconciliation
was designed with the nurse, physician, and patient in mind. In the beginning, the
hospital system considered several factors: change theory, adult-learner theory, additional
paperwork, staffing crises, and the typically hectic, busy nature of a nursing
unit. The nurse on the pilot unit as well as the selected physician had to be convinced
that the benefit of medication reconciliation outweighed the burden of yet
another change, more paperwork, and the potential for being overwhelmed. At
first, the medication reconciliation process seemed complicated. Staff members perceived
the additional paperwork as tedious. The nurses were naturally resistant and
reluctant to embrace another change. They needed to know that the ADE team
empathized with them and the ADE team needed the support of the nurses for the
process to be successful.
The process was to compare the patient’s current medications with the medications
that the physician ordered on admission to the hospital. That seemed simple
enough; however, it was a change to the process and procedure, which created a new,
time-consuming, detailed system that was absolutely necessary (and soon would be
supported by policy). Fortunately, when the organization presented the process
change to nurses from the perspective of patient safety, nurses recognized its importance.
After the test of change on the pilot unit by the core individuals involved was
successful, the idea was to spread the change. Nurses were beginning to incorporate
and streamline medication reconciliation. The first test of change identified issues
that the health care team had not considered, including the following:
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The Nurse’s Role in Medication Safety
• Nurses had to ask patients for lists of their current medications, which often
were incomplete.
• Physicians had to order new medications that were pertinent to the hospital
diagnosis as well as to the patient’s current medication unless there was a duplication
or an interaction.
• Pharmacists had to evaluate all the medications ordered for food and drug interactions
and drug-drug interactions.
• Nurses were going to ask local pharmacies for pertinent information regarding
patient’s medications over the telephone.
• Family members would be involved to reconcile a patient’s current medication.
The goal was to first make medication reconciliation on admission successful
on the pilot unit and then to spread the process to the emergency department
(ED), then to the remainder of inpatient nursing units, followed by the outpatient
areas, the off-site areas, and eventually on discharge from a hospital.
Diagnosis
Discussion of the current and potential problems for the patient and the nurse
When the Lourdes Hospital system first introduced medication reconciliation,
it was to include one nurse, one physician, and one patient. It was successful on the
pilot unit because of the nature of the unit and the staff working on the unit,
which included the following:
• An extremely dynamic cardiac telemetry unit where change is a daily thing
• Nurses who knew their unit is often chosen for some project or test of change
• A cardiologist whose patient population consisted of people with geriatric and
cardiac issues who were taking several medications
The hospital system initially chose the pilot unit for two reasons: One, a key
member of the ADE team was a charge nurse on that unit, and two, that unit had
(and still has) a highly collaborative relationship with the ED because of the number
of admissions that occur on a daily basis. It only made sense to engage the ED
next. And what a challenge it was. It took several revisions of the medication reconciliation
process to meet the needs of the nurse, physician, and patient who entered
the ED because patients seen belong to several categories, including the following:
• Those who are assessed, treated, and released within an hour
• Those who are assessed, treated, and released after some observation
• Those who are assessed, treated, and admitted
Patients from all walks of life enter the ED: those with disabilities and those
resulting from disasters, those with little or no familial or financial support, those
from nursing homes, and those who are homeless—all of whom need to have their
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Chapter 1: The Nurse’s Role in Medication Reconciliation
medications reconciled when entering the ED.
Very early in the formation of the ADE PFA team, a key component to the
success of this diligent process was to have an energetic, persuasive ED nurse who
regularly attends team meetings and who could drive change. She served not only
as a resource person for the team but as a champion of medication reconciliation
because she believed it to be an important patient safety issue. When presented to
the ED, medication reconciliation was met with the predictable physician and
nurse resistance because it was perceived as time consuming and difficult.
At first, the ED nurses and physicians resisted having to bear the burden of yet
another change and the possibility for more paperwork. (And, yes, the process was
time consuming and difficult to accomplish, in the beginning.) When the test of
change was spread to the ED, it was done on the first day by the one persuasive
nurse team member with one optimistic physician and one patient with a simple
diagnosis and few medications. The ADE PFA team was this nurse’s committee (all
nurses participate in committee membership at Lourdes Hospital) and her colleagues
knew this. She believed in the importance of and accepted the challenge of
medication reconciliation in the ED. Like anything that is repeated, the process
became less complex with each new patient who came to the ED. And, if Lourdes
Hospital’s PFA was patient safety, then it needed to be done 100% of the time.
That was the explanation this nurse team member had to repeat several times a day
until her colleagues were convinced that medication reconciliation was the right
thing to do (and until it would soon be supported by policy).
One complication specific to the ED setting was the fact that patients’ medication
information could be difficult to obtain. At times, the patient had more than
one physician in the community. Some patients could not even begin to report
what medications they took, when they had taken them, or why. Patients from
nursing homes had their medication lists but those lists were quite extensive. Still
other patients had detailed lists of medications and could reiterate exactly when
they took their last dose—medication reconciliation for those patients was relatively
easy. In addition to the patients themselves, the nurses found they could rely on
different sources of information to obtain accurate medication lists for their
patients (for example, family members, local pharmacies, old charts, histories and
physicals, and sometimes even the medication container labels).
After the pilot unit and the ED adopted the process and after the ADE team
provided intensive education for the nurses, pharmacists, and physicians, the
process was very quickly spread to all inpatient and outpatient areas, including
diagnostic imaging, perioperative services, ambulatory surgery, the GI laboratory,
off-site physician offices, hospice, and home care. Essentially, the hospital system
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The Nurse’s Role in Medication Safety
implemented medication reconciliation from admission to discharge to avoid any
confusion with nursing and physician documentation, especially because documentation,
by its nature, is ever-changing. National Patient Safety Goal 8 was reiterated
throughout the organization. The words medication reconciliation were incorporated
into most meeting agendas and discussed in most conversations.
Planning
Statement of the specific goals, action plans, and outcomes for patient safety
National Patient Safety Goal 8 defines the purpose of medication reconciliation,
which is to avoid errors of transcription, omission, duplication of therapy, and
drug-drug and drug-disease interactions. The Joint Commission answers the question
as to who is supposed to complete the medication reconciliation process in its
Frequently Asked Questions, which are posted on its Web site. 2 According to the
Joint Commission, there are the following two models:
1. The physician completes the medication reconciliation process when he or she
writes the orders.
2. The pharmacist or nurse completes the medication reconciliation process before
preparing or administering the medications, and then notifies physicians if any
concerns arise.
The team decided that throughout the Lourdes Hospital system every nurse
will ask each one of his or her patients, on admission to the patient care unit, for a
list of the medications they are currently taking and will fill out a medication reconciliation
form accordingly, with a “good faith effort to obtain as complete a list
as possible, within 24 hours or less.” 1 Besides the actual medication, the nurses will
include the following information: dose, route, frequency, reasons for taking the
medication, and the time of the last dose taken.
Creating the Medication Reconciliation Form
The hospital system designed the medication reconciliation form to be used
as a physician order form. (See the Medication Reconciliation/Physician Initial
Medication Order Form in Figure 1-1 on page 17.) After the physician indicates
whether he or she wants the same medications to be continued or stopped, or if
the medications have been ordered by the physician elsewhere on previous order
sheets, the form can be used as an official physician order form. In addition, the
form contains language that indicates how to use the form and that
“herbals/naturals and supplements will not be dispensed to inpatients.” It references
Lourdes Hospital’s Patient Care Services Policy #29, which states that “all
products not regulated by the Food and Drug Administration (for example,
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Chapter 1: The Nurse’s Role in Medication Reconciliation
herbal/natural products) will not be made available to hospital patients.” A multidisciplinary
team made this decision to prevent adverse drug events, and the
director of the pharmacy and the Lourdes Hospital Patient Care Services Policy
Figure 1-1: Medication Reconciliation/Physician Initial Medication Form
NKA, no known allergies; US, unit secretary; RN, nurse; MD, physician; Pt, patient.
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The Nurse’s Role in Medication Safety
and Procedure Committee approved the form in October 2005.
To promote safe decision making, the form included information on allergies
and intolerances, height, and weight for all patients. Check boxes indicated where
nurses could or would obtain information to complete the form (for example, the
patient, their medication list, the family, the outpatient pharmacy). For the form to
be used as a physician order form, the licensed independent practitioner with prescription
privileges was required to sign and date it. Only then was the hospital
pharmacist authorized to prepare the medications for the nurses to administer.
Every patient who entered the hospital’s portals, for any reason, was to have the
medication reconciliation form initiated and completed in 24 hours or less.
From the ADE team’s perspective, the process sounded very simple and
straightforward. But after several tests of change on the pilot unit, the team found
it necessary to accommodate the nurses and physicians who were actually going to
use this form on an hourly basis. Suggestions for change came fast and furiously
from the staff, and each week for many weeks the form was changed. The ADE
team continually readjusted, rearranged, reconfigured, reconsidered, redesigned,
reformatted, and revised the form to meet the safety needs of the patients and staff
members.
Creating a Master Medication List
As the need for medication reconciliation spread throughout the organization,
the team determined that nurses and physicians caring for outpatients (in the primary
care network) needed access to a form with a design similar to the medication
reconciliation form to easily transfer medication information if those patients were
admitted to the hospital. The hospital system charged a small task force of nurses
with designing the Master Medication List that primary care physicians and their
nurses could use each and every time a patient came for an office visit. This form
facilitates the “process of looking at the list when new medications are ordered and
updating the list to reflect any changes in the medication regimen.” 1 And nurses
can keep one copy of the list in the patient’s chart, record any changes to the
patient’s record and the patient’s copy, and return the list to the patient. (See Figure
1-2 on page 19 for the Master Medication List.) To increase physician compliance,
task force members emphasized the benefits to staff nurses and physicians over and
over again, which include the following:
• If the medications are listed, the physician only has to circle or check the same
medications and/or add new ones.
• The physician or nurse does not have to handwrite the very long list of their
patient’s medications in the chart or at each visit.
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Chapter 1: The Nurse’s Role in Medication Reconciliation
• There will be fewer transcription errors.
• The nurse and the patient can discuss exactly what medications are still prescribed
and what medications are no longer necessary.
Figure 1-2: Master Medication List
DOB, date of birth; MD, physician.
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The Nurse’s Role in Medication Safety
• If and when the patient ever needs to be hospitalized, the updated medication
list from the primary care chart can be used with ease as the medication reconciliation/physician
initial medication order form in the hospital chart. The only
items required will be the physician signature, date, and time at the bottom of
the list, and they can be included in the admission paperwork as medications
reconciled and medications ordered, thus saving time and steps and ensuring
each patient’s medication safety.
Creating Medication Cards for Patients
While one task force of nurses was formatting the Master Medication List,
another small task force of nurses from the primary care network was designing a
medication card for patients. The hospital system trialed several tests of change in
one outpatient setting. Once again, it was necessary to enlist the help of a multidisciplinary
team composed of nurses, physicians, and patients (who were going to be
using this medication card). Not only did the medication card list the patient’s
demographics and the primary care physician’s name and telephone number, it contained
a section for the patient’s brief medical history, a place to denote
allergies/intolerances, and a grid in which to list current medications (including
herbals and supplements and over-the-counter drugs) that the patient was currently
taking. The grid also included a place to list the dose (by simply asking, “How
much?”), the route, the frequency (by asking, “How often?”), and the reason why.
(The language used was basic to facilitate teaching and learning.) This grid on the
patient’s medication card was designed exactly like the columns on the inpatient
medication reconciliation form. Soon, all patients who entered the outpatient arena
would be given instructions on how to fill out their medication cards. They were
also instructed to bring these cards with them each time they had an office visit so
that their medication lists could and would be updated, ensuring their safety. (See
the medication card for patients in Figure 1-3 on pages 21–22.)
For those patients who have not received a medication card from the outpatient
setting, a blank card is included in the paperwork for all patients who are
admitted and discharged from the hospital. Often nurses on these units assist
patients or their families with filling out the medication cards. Nurses encourage
patients to update their medication cards at discharge. The Lourdes system has
found that it only takes a few moments for a nurse to teach a patient about the
importance of the right drug, dose, route, and the reason for their medications. At
the same time, nurses can give medication-information teaching sheets to patients
and their family members. These sheets describe any new medication initiated as
well as dosage, administration, side effects, and contraindications. This is not a new
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Chapter 1: The Nurse’s Role in Medication Reconciliation
Figure 1-3: Medication Card for Patients
Continued on next page
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The Nurse’s Role in Medication Safety
22
Figure 1-3: Medication Card for Patients (continued)

Chapter 1: The Nurse’s Role in Medication Reconciliation
practice because pharmacies across the nation are compelled to provide medicationinformation
teaching sheets for any drug that is dispensed.
Medication Reconciliation in Home Care and
Hospice
Another area of concern for appropriate medication reconciliation was within
home care and hospice. To ascertain that every patient in the system would have
their medications reconciled, Lourdes’s home care agency, Lourdes at Home (LAH),
and the Lourdes Hospice Program were included in the medication reconciliation
process. LAH nurses reconciled their patients’ medications using a slightly different
form (see Figure 1-4 on page 24). Every single time an LAH nurse entered a
patient’s home, the nurse reconciled medications in the following ways:
• By discussion with the patient or the family
• By the discharge paperwork from the hospital
• With any new prescriptions filled or unfilled
• From the actual medication bottles in the home
• By calling the patient’s primary care physician or local pharmacy
These nurse home care visits created several opportunities for teaching and
learning, while at the same time maintaining patient safety as a top priority.
Similarly, Lourdes Hospice nurses relied mostly on families for the medication
reconciliation, as well as on the primary care physician and local pharmacy. The
hospice forms are simpler, but two strong statements at the bottom of the forms
alert the patient to disclose any and all medications—including herbals, supplements,
and vitamins—they are currently taking so that any possible interactions
could be discussed. (See the hospice care forms in Figures 1-5 on pages 26–27 and
Figure 1-6 on pages 28–29.)
Implementation
Including tasks in the process and documenting observations
Now that the medication reconciliation forms were somewhat finalized—across
the system—it was time to implement the process from the point of entry to the
point of exit.
On the inpatient side of the hospital system, each patient’s current medication
list is computer generated every night at midnight. The nurses’ medication administration
records (MARs) for their patients are also computer generated every night
at midnight. During the day shift, patients (or their family members if patients are
unable to comprehend it) receive their current medication list. The patient copy of
the list (entitled “Postop/Transfer Medication Reconciliation Record”) is similar in
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The Nurse’s Role in Medication Safety
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The Nurse’s Role in Medication Safety
26
Figure 1-5: Hospice Medication Flow Sheet As-Needed Medications

Chapter 1: The Nurse’s Role in Medication Reconciliation
Figure 1-5: Hospice Medication Flow Sheet As-Needed Medications (continued)
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The Nurse’s Role in Medication Safety
28
Figure 1-6: Hospice Medication Flow Sheet Routine Medications

Chapter 1: The Nurse’s Role in Medication Reconciliation
Figure 1-6: Hospice Medication Flow Sheet Routine Medications (continued)
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The Nurse’s Role in Medication Safety
30
assessed and initially treated, the primary nurse in the ED asks for her current list
of medications. The patient produces a Lourdes Hospital medication card from her
wallet that contains an up-to-date list of her medications, the doses in milligrams,
the times she takes them, and why. Her primary care physician’s name and telephone
number and an emergency contact and telephone number are also on the
card, as well as a brief summary of her health history, her allergies, and a list of
questions to ask about herself. Because she is alert and oriented and has been initially
treated for dyspnea, the patient is able to tell the ED nurse exactly what
medication she has already taken today and what medication she still needs. This
information is then put on the medication reconciliation form that stays with her
chart for the entire hospitalization. When her admitting physician arrives to evaluate
the patient, he can use this form (by simply circling the appropriate words) to
continue the same medications and/or stop other medications and/or order new
medications. By signing the medication reconciliation form at the bottom, the
medication reconciliation form becomes a physician initial medication order form
and is faxed to the pharmacy. At this time, the pharmacy is authorized to prepare
the medications for the nurses to administer. The ED nurse gives a face-to-face
report to the receiving nurse on the telemetry unit together with all that he/she
knows about this patient, including the medication reconciliation information. By
the time the patient arrives on the telemetry unit, her current medications have
been ordered and reconciled, the MAR has been printed, and the medications that
the patient did not already take today are ready to be administered. If there are
any new medications ordered or current medications stopped, the nurse can incorporate
this information into the initial plan of care.
Example 2: A woman in her forties is brought into the ED by paramedics because
she was found wandering a residential neighborhood at 3:00 A.M. She knows who
she is and knows that yesterday was her birthday. She says she was “celebrating”
and her blood alcohol content on arrival was 0.29%. After she is assessed and
treated, the ED nurse attempts to ask her about her health history. The patient
continues to alternate between dozing off and repeating incomprehensible words.
The ED physician decides to admit the patient. The ED nurse cannot possibly
complete the medication reconciliation form, there are no family members present,
and the hospital pharmacy is closed because a 24-hour pharmacy does not exist at
Lourdes Hospital yet. Any retail pharmacy would also be closed at this time of
night and the hospitalist assigned to this admission does not know the patient at
all. When giving the report to the receiving unit, the ED nurse apologizes for the

Chapter 1: The Nurse’s Role in Medication Reconciliation
incomplete medication reconciliation form and asks the receiving nurse to make a
“good faith effort” in the morning toward reconciling this patient’s medications.
The next morning, the patient is more coherent and is questioned about any and
all medications that she may have been taking prior to her admission to the hospital.
At this time, the patient is able to state to her nurse what she takes but does
not know the doses and she cannot remember anything about the day before. She
uses a local pharmacy and has given the nurse permission to contact the pharmacy
to obtain the medications and doses she takes. The nurse on the medical unit to
which the patient is assigned places a call to the pharmacy, and identifies herself
and the reason for her call. The local pharmacist asks for the patient’s demographics
and then gives the nurse the requested information as to her patient’s medications
and dosages. The nurse now places a call to the patient’s physician to request
the current medications and appropriate dosages for the patient. (She is taking escitalopram
oxalate, metoprolol, ciprofloxacin, a nicotine patch, and ibuprofen.) Her
medications are reconciled and she is started back on her same drug regimen except
for the over-the-counter ibuprofen. (To prevent any potential gastric reflux or
ulcers, the ibuprofen was discontinued and pantoprazole sodium was ordered, as
well as folic acid, thiamine, vitamins, and diazepam to move her safely through
alcohol withdrawal.)
These two examples are at opposite ends of the spectrum when considering
medication reconciliation, but, as stated previously, it is the primary goal of keeping
patients safe that compels nurses to continue toward completing the medication
reconciliation process, regardless of how difficult this is to accomplish, at every portal
of the system. Most of the time, medication reconciliation is successful because
of the initial steps the nurses take. There has been remarkable success in reducing
adverse drug events with the incorporation of medication reconciliation at Lourdes
Hospital as evidenced by the evaluation and measurement described below.
Evaluation and Measurement
Note success or failure across the system and adopt, amend, or abandon
By August 2005, the goal of medication reconciliation (to reduce nonreconciled
medications to

The Nurse’s Role in Medication Safety
tics above, medication reconciliation is a process that is performed, primarily by
nurses, with success.
The goal for 2007 is to sustain improvement in the percentage of nonreconciled
medications on admission to

Chapter 1: The Nurse’s Role in Medication Reconciliation
• The trusted nurse-patient relationship yields improved outcomes and a plan of
care that can be instituted when medication reconciliation and subsequent medication
safety prevail.
• Nurses are usually the first caregivers whom patients see when entering a health
care system. Medication reconciliation as well as patient teaching takes place at
this time.
• Nurses are usually the last caregivers whom patients see when exiting a health
care system. Medication reconciliation as well as patient teaching takes place at
this time.
• Nurses may use any and all resources to make a good faith effort to ensure that a
patient’s medications are reconciled appropriately. Their perseverance is necessary
at this juncture.
• Nurses may design and use different forms unique to their departments while
staying within the guidelines of medication reconciliation. Their creativity is
helpful at this juncture.
• Nurses perform chart reviews and serve on committees where data is gathered
and where suggestions for changes to the medication reconciliation process are
welcomed.
Looking to the Future
The future design includes using the electronic medical record to record the
patient’s medication history, height, weight, and allergies, with alerts to all members
of the health care team if any of this information is unavailable. The pharmacist
will receive alerts for potential allergic reactions, drug-drug interactions, and drugfood
interactions, as well as alerts based on laboratory results or other patient information.
The system will alert caregivers when medications are scheduled to be
given and will document medication administration in the electronic medication
administration record. These capabilities will also support computerized provider
order entry.
References
1. Miller L., Mannino C.A.: Taking the Lead in Medication Reconciliation. The Cerner
Quarterly 2(2):40–47, 2006.
2. The Joint Commission: FAQ’s for the 2006 National Patient Safety Goals. http://www.joint
commission.org/NR/rdonlyres/7C116D6D-AE82-449E-BA45-1DE49D2A0A34/
0/06_npsg_faq.pdf (accessed Jan. 22, 2006; site now discontinued).
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