1 Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland (Messrs Khaleghzadegan and Hill, Drs Kachalia, Winner, and Thompson, and Ms Holzmueller); Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland (Dr Kachalia); The Johns Hopkins Hospital, Baltimore, Maryland (Drs Natterman and Paine); The Johns Hopkins Health System, Baltimore, Maryland (Drs Natterman and Paine); Johns Hopkins University School of Nursing, Baltimore, Maryland (Drs Winner and Thompson); Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr Thompson); and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Dr Thompson).