A system analysis of a suboptimal surgical experience.
Lee R, Cooke DL, Richards MR. A system analysis of a suboptimal surgical experience. Patient Saf Surg. 2009;3(1):1. doi:10.1186/1754-9493-3-1.
A post-surgical complication experienced by one of the authors—himself a patient safety researcher—is examined in detail using root cause analysis.