Chris Johnson, Index
Incident Reporting:
Problems of Data Analysis (A&E)
- Fewer organisational causes:
- less effective protocols than A&E;
- eg which drugs to stock and when;
- "when it goes right, it's boring";
- didnt consider safety implications...
- More technical causes:
- mostly design problems;
- lack of training in new systems.
- (Direct) human causes?
- didnt check system before use;
- slips & lapses (forgetting...)
