It is estimated that one in 300 patients admitted to hospital will die or be seriously injured as a result of medical errors (Chief Medical Officer 2009), many of which will be caused by human factors. This article examines a case study in which team error led to the death of a patient. It discusses some of the contributing human factors that were involved and explores possible ways to improve patient safety through education in human factors and non-technical skills.
Nursing Standard. 26, 26, 43-48. doi: 10.7748/ns2012.02.26.26.43.c8972
Correspondence Peer reviewThis article has been subject to double blind peer review
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