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Brugler L, DiPrinzio MJ, Bernstein L.Brugler L, et al.Jt Comm J Qual Improv. 1999 Apr;25(4):191-206. doi: 10.1016/s1070-3241(16)30438-2.Jt Comm J Qual Improv. 1999.PMID: 10228911