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Commentary
A practical tool to learn from defects in patient care.
June 28, 2010
Pronovost P, Holzmueller CG, Martinez EA, et al. Jt Comm J Qual Patient Saf. 2006;32(2):102-108.
The authors describe a tool for investigating incidents and making necessary safety improvements. The tool was developed at Johns Hopkins and funded by the Agency for Healthcare Research and Quality.
