Application in the accident causation model

In this section, a real case is presented so that the accident causation model can be applied to identify the root cause of the errors (BBC News, 1999a-g). 

Case morphine injection fatal medication errors 

Baby LW was given a dose of morphine which was 100 times stronger than it should have been. The death certificate said Baby LW died from a brain disease and breathing difficulties. 

Baby LW, who was born 7 weeks prematurely and had difficulty breathing, was given the morphine to sedate her. Dr HE (Senior House Officer) is alleged to have miscalculated the amount of morphine that 

Dr VM (Senior Registrar) was given the morphine and reportedly failed to spot that the dosage was too high. 

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