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. 2018 May;19(2):155-160.
doi: 10.1177/1751143717735203. Epub 2017 Oct 3.

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

Anika Sud  1 , Piotr Szawarski  1
Affiliations

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

Anika Sud et al. J Intensive Care Soc. 2018 May.

Abstract

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.

Keywords: Accountability; error; human factors.

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