Classic cases revisited – Death of a nurse and the anatomy of error | Zendy

A. Sud | Zendy; Piotr Szawarski | Zendy

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Classic cases revisited – Death of a nurse and the anatomy of error

Author(s) -

A. Sud,

Piotr Szawarski

Publication year - 2017

Publication title -

journal of the intensive care society

Language(s) - English

Resource type - Journals

SCImago Journal Rank - 0.551

H-Index - 14

eISSN - 2057-360X

pISSN - 1751-1437

DOI - 10.1177/1751143717735203

Subject(s) - causation , verdict , accountability , medication error , drug administration , medicine , psychology , law , patient safety , health care , political science

The tragic case of Mayra Cabrera who died as a result of wrong route drug administration is notable as it was the first time a verdict of unlawful killing was recorded against an NHS Trust. Error within medicine is a significant cause of patient morbidity and mortality. We explore the costs of error, the dynamics of error causation, the role of both the individual and institution in accountability for error, as well as transferrable lessons from other industries to reduce error.

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