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PSNet: Patient Safety Network
Journal Article

Using system analysis to build a safety culture: improving the reliability of epidural analgesia.

Garnerin P, Huchet-Belouard A, Diby M, et al. Acta anaesthesiologica Scandinavica. 2006;50:1114-9.

The authors describe the systematic analysis of an incident involving inappropriate use of a medical device and discuss how their process for understanding and resolving the problem supported the safety culture in their organization.