Scottish nurse Pauline Cafferkey is believed to have caught Ebola by wearing a visor instead of goggles while treating patients, charity bosses today revealed.
Save the Children chiefs said it is impossible to be completely certain how she caught the virus.
However, it said the different protocols used for removing visors and goggles, was the most likely explanation.
Ms Cafferkey, from Cambuslang, made a full recovery after being treated in London.
Justin Forsyth, Save the Children chief executive, said: "I am delighted for Pauline Cafferkey and her family that she has fully recovered from Ebola.
"Pauline is a dedicated humanitarian who worked tirelessly and selflessly in the fight against Ebola.
"We will never be 100% sure how Pauline contracted Ebola.
"But the independent panel found that it is most likely, though not conclusive, she acquired her illness while working at the Ebola Treatment Centre at Kerry Town in Sierra Leone.
"It thought it unlikely that Pauline contracted the disease while in the local community.
"The panel found that the Save the Children procedures, equipment and protocols at the ETC are safe and meet all required standards and that training is of a good standard.
"Working under such intense and challenging conditions, however, cannot be without risk.
"Although there is no conclusive evidence, the panel suggests that Pauline's use of a visor, within a context geared to the use of goggles, was the most likely cause of her contracting Ebola.
"Both visors - used by UK Ministry of Defence staff and recommended by the World Health Organisation - and goggles, which are used by STC after consultation with M�decins Sans Fronti�res, are safe but there are slight differences in the clothing used with each and the protocols for putting the equipment on and taking it off.
"The panel found that where STC approved protocols may not have been followed, or where prescribed equipment was not used, they weren't picked up immediately and therefore action might not have been taken quickly to correct them.
"Lessons have already been learned and as a result of the findings we have further tightened our protocols and procedures.
"These include refresher training of the use of Personal Protective Equipment (PPE) and working within 'risk zones'; improved logging of potential incidents; and, all changes in PPE protocol must be signed off by the ETC director.
"STC has robust and strict protocols in place to protect our staff and the communities we seek to serve.
"We maintain confidence in both our equipment and our protocols, as long as they are followed properly. But we keep them under constant review. Staff safety is our number one priority."
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