Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids.
Approach to Improving Safety
Setting of Care
Although there have been no reported accidental spinal injection of a vinca alkaloid in the United Kingdom since 2001, this study looked at upstream safety issues that could cause this fatal complication. The method used in this study provides a model for evaluating the resilience of safety practices, even in the absence of actual harmful events.