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About the Author. Introduction: Why do we still miss appendicitis? Clinical incident investigation: Background and context. How do we recognise patient safety incidents that need in-depth investigation? Recognising serious patient safety incidents using the SIRT: Case studies. A culture of complaint: Openness, candour and blame. RCA: Understanding what happened. RCA: Understanding how. RCA: Understanding why. Understanding why: System factors. Understanding why: Human error, Part
1. Understanding why: Human error, Part 2: Situational awareness and high-pressure environments. Root cause. Learning and recommendations. Solution design and changing cultures. Writing reports. Glossary. Index.