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The story of Mrs. Mary McClinton walks us through a pivotal moment in the change of culture for Virginia Mason. The tragedy of Mrs. McClinton's

The story of Mrs. Mary McClinton walks us through a pivotal moment in the change of culture for Virginia Mason. The tragedy of Mrs. McClinton's case highlights a system error. Too often, individuals are blamed, and mistakes are left to happen again. Virginia Mason recognized a system error and went about creating a culture of safety. Discuss the evolution of the PSA System and its importance.

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