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International Journal for Quality in Health Care 14:519 (2002)
© 2002 International Society for Quality in Health Care

Every Defect is a Treasure

Inadequate monitoring in the absence of a treatment protocol leads to an adverse outcome

The first 10% of the full text of this article appears below.

A 77-year-old man is discharged from the hospital 30 minutes after removal of a surgical drain and dies en route to a family celebration.

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