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.
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 2017Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated softwareConflict Of Interest