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Implementing strategies to identify and mitigate adverse safety events: a case study with unplanned extubations.
Hatch LD, Rivard M, Bolton J, et al. Jt Comm J Qual Patient Saf. 2019;45:295–303.
The authors describe how the use of statistical process control charts facilitated rapid identification of a cluster of unplanned extubations in a neonatal intensive care unit. They advocate for the use of continuous monitoring tools to help alert teams to possible safety events and improvement opportunities.