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Analyzing and mitigating the risks of patient harm during operating room to intensive care unit patient handoffs.

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Patients continue to suffer from preventable harm and uneven quality outcomes. Reliable clinical outcomes depend on the quality of robust administrative systems and reliable support processes. Critically ill patient handoffs from the operating room (OR) to the intensive care unit (ICU) are known to be high-risk events.

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A conceptual framework for identifying and managing system vulnerabilities for diversion of controlled substances in healthcare.

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