Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids

BACKGROUND: Catastrophic errors in healthcare are rare, yet the consequences are so serious that where possible, special procedures are put in place to prevent them. As systems become safer, it becomes progressively more difficult to detect the remaining vulnerabilities. Using inadvertent intratheca...

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Main Authors: Franklin, Bryony Dean, Panesar, Sukhmeet S, Vincent, Charles, Donaldson, Liam J
Format: Artigo
Jezik:Inglês
Izdano: BMJ Publishing Group 2014
Teme:
Original Research
Online dostop:https://ncbi.nlm.nih.gov/pmc/articles/PMC4145437/
https://ncbi.nlm.nih.gov/pubmed/24643293
https://ncbi.nlm.nih.govhttp://dx.doi.org/10.1136/bmjqs-2013-002572
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