Understanding the role of non-technical skills in patient safety.

It is estimated that one in 300 patients admitted to hospital will die or be seriously injured as a result of medical errors (Chief Medical Officer 2009), many of which will be caused by human factors. This article examines a case study in which team error led to the death of a patient. It discusses some of the contributing human factors that were involved and explores possible ways to improve patient safety through education in human factors and non-technical skills.