Key result
A complex interaction of system and human factors led to errors in the recognition and nursing management of a deteriorating patient, ultimately resulting in death.
Case Report (n=1)
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Understanding the complex interaction of system and human factors in nursing management errors can help identify strategies to prevent similar incidents.
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.
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Heather Gluyas (2017) conducted a case report in Deteriorating patient (n=1). Errors in nursing management was evaluated on Death. A complex interaction of system and human factors led to errors in the recognition and nursing management of a deteriorating patient, ultimately resulting in death.
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