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PSNet: Patient Safety Network
Journal Article
Study

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

Hu Y-Y, Arriaga AF, Roth EM, et al. Annals of surgery. 2012;256:203-10.

Analysis of video recordings of 10 complex surgical procedures identified an average of 3 deviations (delays or patient safety concerns) per procedure, most often due to problems with communication or environmental design.