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Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.
Steinberger DM, Douglas SV, Kirschbaum MS. Prog Transplant. 2009;19:208-215.

Failure mode and effects analysis was used to identify vulnerable handoff and communication processes in organ procurement and transplantation. A communication error led to the widely publicized death of a lung transplant patient at Duke University Medical Center in 2003.

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