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PSNet: Patient Safety Network
Journal Article
Study

Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors.

Kostopoulou O, Delaney B. Quality & safety in health care. 2007;16:95-100.

This observational study analyzed nearly 80 reported events, many of which were near misses, and found that failures in cognitive activity often created the potential for harm. In addition to promoting the implementation of accepted ambulatory-based safety practices, the authors advocate for greater research on the relationship between clinical and administrative decision-making and adverse events.