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Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.
Hu YY, Arriaga AF, Roth EM, et al. Ann Surg. 2012;256:203-210.

Analysis of video recordings of 10 complex surgical procedures identified an average of 3 deviations (delays or patient safety concerns) per procedure, most often due to problems with communication or environmental design.
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