Learning from adverse events and errors is important if systems and processes are to be improved and to minimise the likelihood of similar events in the future. This article uses the report from a coroner’s inquest into the death of a seven-year-old child in hospital to examine errors that contributed to the child’s death. These errors are reviewed from a human factors perspective. The article provides an overview of error causation concepts and offers strategies that healthcare organisations can implement to reduce the incidence of such errors.
Nursing Standard. 30, 31, 46-51. doi: 10.7748/ns.30.31.46.s45Correspondence
All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Received: 05 May 2015
Accepted: 06 November 2015
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