BSI International Health Technology Consulting |
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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:
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