Errors in the nursing management of a deteriorating patient
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Errors in the nursing management of a deteriorating patient

Heather Gluyas Associate professor, School of Health Professions, Murdoch University, Perth, Western Australia

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.

Correspondence heather.gluyas@gmail.com

Nursing Standard. 32, 12,41-50. doi: 10.7748/ns.2017.e10874

Received: 29 March 2017

Accepted: 11 September 2017

Published in print: 15 November 2017

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Conflict Of Interest

None declared