Pediatric Qual Saf
https://pubmed.ncbi.nlm.nih.gov/?myncbishare=dukemlib&dr=abstract&otool=dukemlib&term=33409427
This group organized a new process for their peer review that moved away from individual provider clinical competence. Most of the issues examined involved system errors. There was an emphasis on this as a nonpunitive methodology that was intended to correct problems and improve the delivery of healthcare