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While most studies suggest that user error (or "use error") is the primary cause of most patient incidents, the extensive experience accumulated by BSI consultants shows that user error is NOT the only factor or even, in many cases, the single most important factor.  In the majority of cases, it is necessary to have more than one failure (human, system, or machine) for an incident to happen, especially when an injury or death happened.

When investigating an incident, all possible factors must be considered, such as:

bulletfundamental lack of understanding of the clinical environment by the designers
bulletengineering design that did not consider all risk factors
bulletpoor man-machine interface (ergonomics)
bulletunclear interactions among multiple technologies used at the same time
bulletinsufficient inservice training
bulletinadequate warnings and instructions

Please contact BSI to understand how we can help you

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reduce your liability exposure

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defend your organization in lawsuits

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get compensation from manufacturers and clinicians for design flaws and user errors

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produce a safer, better product

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Contact Information

Electronic mail info@BSI-Consulting.com

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Copyright 2004-10 by BSI.  All rights reserved - Updated: 07/25/10