Effective management of the deteriorating patient requires early recognition of the signs of deterioration, timely review and appropriate interventions. However, this does not always occur. Errors in the recognition and management of a deteriorating patient are rarely related to a single factor; rather they are a complex interaction of system and human factors. This article presents a case study focusing on understanding the factors that led to errors resulting in the death of a patient. Understanding the complex interaction of system and human factors enables the identification of strategies that could be used to decrease the likelihood of a similar incident occurring.
Nursing Standard. 32, 12, 41-50. doi: 10.7748/ns.2017.e10874Correspondence
This article has been subject to external double-blind peer review and checked for plagiarism using automated softwareConflict of interest
Received: 29 March 2017
Accepted: 11 September 2017
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