• Figure 1.

    Reason’s “Swiss cheese” model of error

  • Figure 2.

    As Settings Of Care become more complex , the Importance of Creating safe systems grows.

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    Leape LL. Error in medicine. JAMA 1994; 272:18517.

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    Gawande A. On washing hands. N Engl J Med 2004; 350:12836.

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    Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. Trustees of Columbia University, 2001.

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    Seliger SL, Zhan M, et al.. Chronic kidney disease adversely influences patient safety. J Am Soc Nephrol 2008; 19:2414.

Patient Safety: General Principles and the Role of the Nephrologist

Henry Crevensten
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Robert Wachter
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