Chris Johnson, Index

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Incident Reporting:
Problems of Data Analysis

• Anaesthesia study:
  - already had a reporting system;
  - different hospital from A&E study;
  - incidents over 3 month period.
  
  
• Analysis stages as before.
  
  
• 15 incident descriptions:
  - 78 root causes (5.2 ave);
  - 27% organisational causes;
  - 40% (direct) human causes;
  - 26% technical causes.

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