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The audit, Mr. Rogan said, was a reaffirmation to agency officials that changes aimed at improving procedures were needed.
Compensating victims and improving procedures is more fruitful than trying to pin blame.
"We did not find an institution or culture that provided a safe outlet for admitting errors and improving procedures," the report said.
Forcelli recently rewrote the A.T.F.'s manual on eyewitness identifications, with the aim of improving procedures in order to safeguard against error.
An American Hospital Association official, Nancy Foster, said the study highlighted the importance of improving procedures to prevent the medication errors and other problems described in the report.
I organized a series of conference calls with our analytical experts back home, reviewing and improving procedures alongside local staff.
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All our factories are constantly reviewed to ensure we improve procedures and processes.
In exchange, the government would hire more staff members and improve procedures to allow for speedier product reviews.
They will have to do it themselves, with their presumably improved procedures for accepting mortgages.
Since then, efforts have been made to improve procedures – and recent surveys of all NHS staff have shown higher levels of confidence about reporting concerns.
They said there was a need to improve procedures for monitoring and preventing suicide, self-harm and bullying.
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