External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.
Approach to Improving Safety
- Quality Improvement Strategies
- Communication between Providers
- Human Factors Engineering
- Culture of Safety
- Technologic Approaches
- Education and Training
Setting of Care
This UK Department of Health report details a series of errors that led to the death of a young man due to wrong route administration of the chemotherapy drug vincristine. The fatality occurred as a result of a socio-technical systems failure at the hospital where he received the injection. The report makes 48 recommendations to help minimize the likelihood of this mistake.