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PSNet: Patient Safety Network
Journal Article

National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths.

Hickey EJ, Nosikova Y, Pham-Hung E, et al. The Journal of thoracic and cardiovascular surgery. 2015;149:496-505; discussion 505-7.

In this study, the National Aeronautics and Space Administration's error detection model was used to analyze the incidence and types of error in pediatric cardiac surgery procedures. The investigators found that errors occurred in nearly half of all operations and frequently manifested as cycles of error whereby the effect of a single error was compounded by failure to rescue.