Summary
The Patient Safety Network (PSNet) discuss a case of a 65 year old who went in for one operation, but ended up having a completely different operation.
Content
In this article they use this case to highlight the importance of analysing errors using a systems approach. James Reasons 'Swiss cheese model of medical errors' is explained and put into context.
PSNet: Systems Approach
https://psnet.ahrq.gov/primers/primer/21
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