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Fatal Hospital Sentinel Event in Australia Caused By Combination of Errors and Failures

This short newspaper article starts to provide the information needed to draw a SnapCharT® that would have many Causal Factors. Read the story and then try drawing a SnapCharT®.

Link to story:

http://www.news.com.au/heraldsun/story/0,21985,23323474-29277,00.html

This entry was posted on Saturday, March 8th, 2008 at 5:26 am and is filed under Accidents, Current Events, Medical/Healthcare, Investigations, Root Causes. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

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