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Commentary
Beyond the organisational accident: the need for "error wisdom" on the frontline.
Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33.
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April 6, 2011
Reason J. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33.
This commentary uses a case study involving a fatal medication error to illustrate the importance of mental skills that improve recognition of potentially adverse events.
