Historical Disasters

Question 1

Charles Perrows Normal Accident Theory

Answer 1

• Accidents occur due to unanticipated interaction of multiple failures in a complex system
• Interpreted as “normal” by inevitability of complex systems
• Trivial events cascade into a large event with severe consequences

Question 2

Dana-Farber Chemotherapy Incident

Answer 2

• Overdose from cyclophosphamide
• Led to better error reporting and responsibility
• Partnerships were developed like Mass. Coalition for Prevention of Medication Errors
• Betsy Lehman Center for Patient Safety was established

Question 3

Transdermal Fentanyl Incidents

Answer 3

• Used to treat acute pain in opioid naive patients despite CI
• Issues with practitioner knowledge about this black box warning
• Also see “bystander apathy” in regards to the patch’s ingestion or improper disposal

Question 4

Heparin Incidents

Answer 4

• Several neonates died or were affected by incorrect heparin stoarge in Pyxis (10,000 u/mL instead of 10 u/mL vials)
• No regulatory or accrediting bodies required any implementation of risk-reduction activities after the incidents

Question 5

New Mexico Errors

Answer 5

• Magnesium overdoses leading to death
• Misinterpretation of drug name leading to brain death (Dialume instead o Diabinese)
• Misinterpretation of doctors orders leading to incorrect, high dosing leading to stroke and inability to speak