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To help hospital staff learn from a medical device-related incident, Amoore and Ingram developed an anonymous feedback framework that included a description of the incident, its cause, lessons learnt, corrective actions taken, and interventions to help prevent errors [ 19].
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The objective of this article is to review a selection of major incidents involving ammonium nitrate in the last century to identify common causes and lessons that can be gleaned from these incidents in the hopes of preventing future disasters.
Whatever the position on whether constraints count as causes, the lesson to be taken from this part of the adaptationism debate is that it is essential to precisely specify the rival evolutionary hypotheses.
She's a member now, one of 20 chosen each year for their contribution to the cause and given lessons in ideology and behaviour: "We have to welcome everybody, to be polite but serious".
Activities included error prevention, restructuring patient safety governance, a root cause analysis program, lessons learned program, and tactical intervention for high-risk areas.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com