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PSNet: Patient Safety Network
Journal Article
Commentary

A practical tool to learn from defects in patient care.

Pronovost PJ, Holzmueller CG, Martinez E, et al. Joint Commission journal on quality and patient safety. 2006;32:102-8.

The authors describe a tool for investigating incidents and making necessary safety improvements. The tool was developed at Johns Hopkins and funded by the Agency for Healthcare Research and Quality.