In a quality system how are  errors handled?

A quality system focuses on:

• systems and processes rather than individual performance

• reporting errors without fear of blame

• root cause analysis to identify actual cause and contributing factors

• culture of questioning and constant learning

In this case the system failed. Important contributory factors included

• absence of formal and documented training and competency assessment programs

• staff communication difficulties

Further Reading

• Elements of a quality system (London Laboratory Services Group)