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Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.
October 28, 2009
Steinberger DM, Douglas S, Kirschbaum MS. Prog Transplant. 2009;19(3):208-14; quiz 215.
Failure mode and effects analysis was used to identify vulnerable handoff and communication processes in organ procurement and transplantation. A communication error led to the widely publicized death of a lung transplant patient at Duke University Medical Center in 2003.
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