Reviewer comments: This eSEA covers a simple mix up in booking the correct patient in to the practice. The report identifies the issues this caused. While no harm was done this is still a good event to analyse. The analysis shows good use of human factors which could be replicated in the future. Learning has been demonstrated leading to a good action plan.
This eSEA is a good example of how to use human and system factors when carrying out analysis of an event.