Beyond the organisational accident: the need for "error wisdom" on the frontline.

J Reason

Commentary

Beyond the organisational accident: the need for "error wisdom" on the frontline.

March 6, 2005

Reason J. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33.

View more articles from the same authors.

This commentary uses a case study involving a fatal medication error to illustrate the importance of mental skills that improve recognition of potentially adverse events.

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