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Cited article:

Human Factors Analysis of a Near-Miss Event: Oxygen Supply Failure During Cardiopulmonary Bypass

Bruce D. Spiess, John Rotruck, Harry McCarthy, Olga Suarez-Wincosci, Vigneshwar Kasirajan, Joyce Wahr and Scott Shappell
Journal of Cardiothoracic and Vascular Anesthesia 29 (1) 204 (2015)
https://doi.org/10.1053/j.jvca.2014.08.011