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Search results for "Error Reporting"
Journal Article > Study
Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids.
Franklin BD, Panesar SS, Vincent C, Donaldson LJ. BMJ Qual Saf. 2014;23:765-772.
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.
Journal Article > Commentary
Noble DJ, Donaldson LJ. Qual Saf Health Care. 2010;19:323-326.
Accidental administration of the intravenous chemotherapy agent vincristine into the sac around the spinal cord is almost invariably fatal. This error has been recognized since vincristine was first used in the 1960s and is now classified as a never event, but it has not been eliminated despite vigorous efforts. This article reviews the history of safety initiatives around vincristine and identifies five domains of failure, ranging from failure to adequately investigate cases to failure to translate safety solutions internationally. A fatal vincristine error that occurred in the United Kingdom was the subject of a detailed investigation commissioned by the National Health Service. One of this article's authors, Sir Liam Donaldson, was interviewed by AHRQ WebM&M in 2007.