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. 2022 May 13;37(5):422–428. doi: 10.1097/JMQ.0000000000000062

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Figure. — The review process after a patient with COVID-19 died in a Johns Hopkins Health System (JHHS) hospital. Concerns about preventability moved the case to the next level for review by a larger group of content experts (level 2) or by leadership and care team members where the patient died (level 3). A rapid cycle root cause analysis (RCA) could be requested at any time if there was concern about a significant system or process of care issue.