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PSNet: Patient Safety Network

The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures and Lack of Mindfulness.

Anderson-Fletcher E, Vera D, Abbott J. Houston, TX: Hobbs Center for Public Policy, University of Houston; 2015.

The high-profile misdiagnosis of a patient with Ebola in the United States serves as a key example of how system factors can contribute to diagnostic error. This analysis of the incident breaks down what happened and explores how attention to mindfulness and organizational culture can improve the safety of care processes.