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Commentary
Early warnings, weak signals and learning from healthcare disasters.
May 20, 2014
Macrae C. BMJ Qual Saf. 2014;23(6):440-5.
This commentary examines how minor risks, when propagated and not addressed, may result in organizational disasters, as evidenced in the Francis report. The author advocates for early detection of workarounds and routine investigations into system causes of errors to reveal latent safety hazards in health care.
