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PA-PSRS Patient Saf Advis. September 2005;2:1-5.
This article draws from the reporting system in Pennsylvania to discuss lost surgical pathology specimens and recommend a systems-oriented approach to improvement.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.