Acknowledgments |
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ix | |
Preface |
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xi | |
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Chapter 1 Medical Competence and Patient Safety |
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1 | (32) |
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Competence as Individual Virtue or Systems Issue? |
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2 | (3) |
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Why the Difference in Competence Assumptions? |
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5 | (2) |
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Good Doctoring and the Pursuit of Perfection |
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7 | (8) |
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From Sacred Status to Contractual Duty |
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8 | (2) |
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The Symbolic Importance of Medical Competence to This Day |
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10 | (5) |
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Standardization and the Fear of Scientific-Bureaucratic Medicine |
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15 | (7) |
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Getting the Job Done Despite the Organization |
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18 | (3) |
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Standardization: Yes or No? |
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21 | (1) |
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The Expectation of Perfection versus the Inevitability of Mistake |
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22 | (6) |
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Infallibility, Error, and Technical Advances in Medicine |
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26 | (2) |
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28 | (1) |
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29 | (4) |
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Chapter 2 The Problem of "Human Error" in Healthcare |
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33 | (32) |
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33 | (3) |
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The Human Factors Approach |
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36 | (8) |
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Error and Expertise Are Two Sides of the Same Coin |
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43 | (1) |
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Human Error as Attribution and Starting Point |
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44 | (2) |
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"I Knew This Could Happen!" |
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46 | (9) |
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46 | (3) |
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49 | (2) |
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51 | (1) |
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Why Are These Biases So Pervasive? |
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52 | (1) |
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Judging Instead of Explaining |
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53 | (2) |
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The Local Rationality Principle |
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55 | (5) |
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Human Error as a Rational Choice |
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56 | (1) |
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Error as the By-Product of Normal Work |
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57 | (2) |
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The Accountability Backlash |
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59 | (1) |
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60 | (1) |
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61 | (4) |
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Chapter 3 Cognitive Factors of Healthcare Work |
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65 | (18) |
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66 | (5) |
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Cognitive Fixation and Vagabonding |
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66 | (2) |
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Escalation and Dynamic Fault Management |
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68 | (1) |
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Multitasking and Prospective Memory |
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69 | (2) |
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71 | (6) |
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Buggy Mental Models, Heuristics, and Oversimplifications |
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72 | (4) |
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76 | (1) |
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77 | (3) |
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80 | (1) |
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80 | (3) |
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Chapter 4 New Technology, Automation, and Patient Safety |
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83 | (16) |
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83 | (6) |
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The Transformative Effects of Technology |
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85 | (3) |
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New Technology beyond Task-Specific Devices |
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88 | (1) |
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89 | (1) |
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90 | (2) |
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Evaluating and Testing Medical Technology |
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92 | (4) |
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The Envisioned World Problem |
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94 | (2) |
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96 | (1) |
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97 | (2) |
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Chapter 5 Safety Culture and Organizational Risk |
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99 | (40) |
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Safety Culture and Drifting into Failure |
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100 | (2) |
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Risk as Energy to Be Contained |
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102 | (8) |
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102 | (5) |
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How to Avoid Man-Made Disasters |
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107 | (1) |
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108 | (2) |
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110 | (5) |
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Risk as the Gradual Acceptance of the Abnormal |
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115 | (13) |
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The Normalization of Deviance |
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115 | (5) |
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How to Prevent the Normalization of Deviance |
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120 | (2) |
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Structural Secrecy and Practical Drift |
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122 | (3) |
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Clinical Guidelines and Patient Safety |
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125 | (3) |
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Risk as a Managerial or Control Problem |
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128 | (8) |
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128 | (5) |
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133 | (3) |
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136 | (1) |
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137 | (2) |
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Chapter 6 Practical Tools for Creating Safety |
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139 | (48) |
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Safety Reporting and Organizational Learning |
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139 | (12) |
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What Is Organizational Learning? |
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139 | (1) |
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Effective Reporting Systems: Nonpunitive, Protected, Voluntary |
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140 | (3) |
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143 | (3) |
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Getting People to Report and Keeping Up the Reporting Rate |
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146 | (2) |
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Root Causes and Responsibilities |
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148 | (1) |
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How Should Your Safely Department Look? |
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148 | (3) |
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Adverse Event Investigations |
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151 | (14) |
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151 | (2) |
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Managing the Hindsight Bias |
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153 | (2) |
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Reconstructing the Human Contribution to an Adverse Event |
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155 | (10) |
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Human Factors and Resource Management Training |
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165 | (12) |
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Communication and Coordination Breakdowns |
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166 | (6) |
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The Fallacy of Social Redundancy |
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172 | (2) |
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174 | (3) |
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177 | (6) |
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What Does a Checklist Do? |
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178 | (2) |
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How Should a Checklist Look? |
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180 | (3) |
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183 | (1) |
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184 | (3) |
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Chapter 7 Accountability and Learning from Failure |
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187 | (26) |
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Learning and Accountability---Just Culture |
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187 | (10) |
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Just Assign Behavior to the Right Category (Right?) |
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188 | (1) |
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Assigning Behavior to Categories Is about Power, Production, and Protection |
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189 | (3) |
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Achieving Organizational Justice |
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192 | (2) |
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Reporting versus Disclosure |
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194 | (1) |
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A Discretionary Space for Accountability |
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195 | (1) |
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Accountability Free Is Not Blame Free |
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196 | (1) |
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Criminalization of Medical Error: A Growing Problem? |
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197 | (8) |
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Crimes as Inherently Real or as Constructed Phenomena |
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197 | (6) |
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Criminalizing Professional Error in Healthcare: Why a Concern? |
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203 | (2) |
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205 | (2) |
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Peer and Employee Assistance |
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206 | (1) |
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207 | (1) |
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208 | (5) |
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Chapter 8 New Frontiers in Patient Safety: Complexity and Systems Thinking |
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213 | (28) |
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Complicated versus Complex |
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214 | (8) |
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Obstetrics, Intervention Decisions, and New Technology |
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215 | (1) |
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Signal Detection in Obstetrics |
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216 | (2) |
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Complexity and Signal Detection |
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218 | (2) |
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Complexity and Technological or Managerial Interventions |
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220 | (1) |
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Complexity, Workarounds, and Compliance |
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221 | (1) |
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Newton, Components, and Complexity |
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222 | (3) |
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The Cartesian-Newtonian Worldview and Adverse Events |
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225 | (10) |
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Newtonian Responses to Failure in Complex Systems |
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228 | (1) |
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Complexity and Its Implications for Understanding Adverse Events |
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229 | (2) |
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A Post-Newtonian Analysis of Adverse Events |
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231 | (4) |
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235 | (1) |
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236 | (5) |
Index |
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241 | |