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.

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Our patient cohort was substantially older and presented at an advanced T status than what is commonly seen in the literature. This may account for poor survival outcomes and the very low pick-up of RET mutations in sporadic medullary thyroid cancer.