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PSNet: Patient Safety Network
Journal Article
Study

Implementing strategies to identify and mitigate adverse safety events: a case study with unplanned extubations.

Hatch D, Rivard M, Bolton J, et al. Joint Commission journal on quality and patient safety. 2019;45:295-303.

The authors describe how the use of statistical process control charts facilitated rapid identification of a cluster of unplanned extubations in a neonatal intensive care unit. They advocate for the use of continuous monitoring tools to help alert teams to possible safety events and improvement opportunities.