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By being able to understand the nature and source of such error(s) we are well placed to identify;
 Risk factors associated with this type of event
Develop a robust risk management strategy
Develop a risk register
Consequently this should improve patient safety and reduce harm
Did the incident analysis reveal the nature and source of error?
What could have been be put in place to prevent such an event occurring
Changes in policy & procedure
Local
Regional
National
summarise the key issues in the case
how the nature & source of error was identified
How the nature & source of the error could be ‘risk managed



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