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Characteristics of patient care management problems identified in emergency department morbidity and mortality investigations during 15 years.
Cosby KS, Roberts R, Palivos L, et al. Ann Emerg Med. 2008;51:251-61, 261.e1.

This study describes a framework for conducting retrospective case analyses and points out the most common contributing factors to patient problems, including management of clinical tasks and poor teamwork.
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