title: Human factors and the death of a child in hospital: a case review.
abstract: Learning from adverse events and errors is important if systems and processes are to be improved and to minimise the likelihood of similar events in the future. This article uses the report from a coroner's inquest into the death of a seven-year-old child in hospital to examine errors that contributed to the child's death. These errors are reviewed from a human factors perspective. The article provides an overview of error causation concepts and offers strategies that healthcare organisations can implement to reduce the incidence of such errors.
authors.affiliation: Murdoch University, Mandurah, Australia.
authors.forename: Heather
authors.initials: H
authors.lastname: Gluyas
authors.affiliation: Royal Perth Hospital and Bentley Hospital, Perth, Australia.
authors.forename: Emily Michelle
authors.initials: EM
authors.lastname: Hookham
mesh_terms: D002648:Child; D003643:Death; D005759:Gastroenteritis / Q000473:pathology*; D006801:Humans
keywords: adverse events; error causation; error prevention; errors; human factors; learning from errors; patient safety