Characteristics of patient care management problems identified in emergency department morbidity and mortality investigations during 15 years.
Cosby K, Roberts R, Palivos L, et al. Characteristics of patient care management problems identified in emergency department morbidity and mortality investigations during 15 years. Ann Emerg Med. 2008;51(3):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.