Identifying systems failures in the pathway to a catastrophic event: An analysis of national incident report data relating to vinca alkaloids

BMJ Quality and Safety

Volumn 23, Issue 9, 2014, Pages 765-772

  Franklin, Bryony Dean ^a,b   Panesar, Sukhmeet S ^c   Vincent, Charles ^c   Donaldson, Liam J ^c  

^a IMPERIAL COLLEGE HEALTHCARE NHS TRUST   (United Kingdom)

^b UNIVERSITY OF LONDON   (United Kingdom)

^c IMPERIAL COLLEGE LONDON   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ANTIBIOTIC AGENT; CYCLOPHOSPHAMIDE; METHOTREXATE; NAVELBINE; VINBLASTINE; VINCA ALKALOID; VINCRISTINE SULFATE; VINDESINE; VINFLUNINE;

ARTICLE; CHEMOTHERAPY; CLINICAL PROTOCOL; CONFUSION; HARM REDUCTION; HAZARD; HEALTH CARE; HOSPITAL PERSONNEL; INCIDENT REPORT; MEDICAL ERROR; PATIENT HARM; PATIENT SAFETY; TREATMENT FAILURE; UNITED KINGDOM; VINCA; ADVERSE EFFECTS; ENGLAND; EPIDEMIOLOGY; FACTUAL DATABASE; HUMAN; MEDICATION ERROR; RISK MANAGEMENT; STANDARDS; STATISTICS AND NUMERICAL DATA; WALES;

DATABASES, FACTUAL; ENGLAND; HUMANS; MEDICATION ERRORS; PATIENT SAFETY; RISK MANAGEMENT; VINCA ALKALOIDS; WALES;

EID: 84906675577     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2013-002572     Document Type: Article

References (37)

1. Noble DJ, Donaldson LJ. The quest to eliminate intrathecal vincristine errors: a 40-year journey. Qual Saf Health Care 2010;19:323-6.
2. Reddy GK, Brown B, Nanda A. Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine? Clin Neurol Neurosurg 2011;113:68-71.
3. Pongudom S, Chinthammitr Y. Inadvertent intrathecal vincristine administration: report of a fatal case despite cerebrospinal fluid lavage and a review of the literature. J Med Assoc Thai 2011;94(Suppl 1):S1-6.
4. Toft B. External inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4 January 2001. http://www.who.int/ patientsafety/news/Queens%20Medical%20Centre%20report%20(Toft).pdf
5. Tannock I. Report on a medication incident of Intrathecal administration of vincristine in Prince of Wales Hospital. 2007. http://www.ha.org.hk/ investigation-panel/pwh/report-eng.pdf
6. Kurtenback E. China shuts down leukemia drug maker. The Associated Press, 2007. http://www.usatoday.com/news/health/2007-12-12-1698973141-x.htm
7. National Patient Safety Agency. Minimising risks of mismatching spinal, epidural, and regional devices with incompatible connectors. 2011. http://www.npsa.nhs.uk/corporate/news/minimising-risks-spinal-devices/
8. ISMP Canada Safety Bulletin. Epidural medications given intravenously may result in death. 2006. http://www.ismp-canada.org/download/safetyBulletins/ ISMPCSB2006-07Epidural.pdf
9. Department of Health UK. The prevention of intrathecal medication errors: a report to the Chief Medical Officer. 2001. http://webarchive. nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH-4065044
10. Australian Council for Safety and Quality in Health Care. Key achievements of the Australian Council for Safety and Quality in Healthcare. MJA 2006;184:S37.
11. World Health Organization. Vincristine sulphate. 2007. http://www.who.int/patientsafety/activities/technical/vincristine/en/index.html
12. National Patient Safety Agency. Vinca alkaloid minibags. 2008. http://www.nrls.npsa.nhs.uk/resources/?entryid45=59890
13. Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieving ultrasafe health care. Ann Intern Med 2005;142:756-64. (Pubitemid 40593778)
14. Lamont T, Beaumont C, Fayaz A, et al. Checking placement of nasogastric feeding tubes in adults (interpretation of x ray images): summary of a safety report from the National Patient Safety Agency. BMJ 2011;342:d2586.
15. Lamont T, Dougall A, Johnson S, et al. Reducing the risk of retained swabs after vaginal birth: summary of a safety report from the National Patient Safety Agency. BMJ 2010;341:c3679.
16. Healey F, Sanders DS, Lamont T, et al. Early detection of complications after gastrostomy: summary of a safety report from the National Patient Safety Agency. BMJ 2010;340:c2160.
17. Lamont T, Watts F, Stanley J, et al. Reducing risks of tourniquets left on after finger and toe surgery: summary of a safety report from the National Patient Safety Agency. BMJ 2010;340:c1981.
18. Lamont T, Scarpello J. National Patient Safety Agency: combining stories with statistics to minimise harm. BMJ 2009;339:b4489.
19. Rocos B, Donaldson LJ. Alcohol skin preparation causes surgical fires. Ann R Coll Surg Engl 2012;94:87-9.
20. Panesar SS, Salvilla SA, Patel B, et al. Laparoscopic cholecystectomy: device-related errors revealed through a national database. Expert Rev Med Devices 2011;8:555-60.
21. Department of Health. HSC 2001/022: National guidance on the safe administration of intrathecal chemotherapy. 2001. http://webarchive. nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/ Lettersandcirculars/Healthservicecirculars/DH-4004769
22. Department of Health. An Organisation With a Memory. 2000. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/ Publicationsandstatistics/publications/publicationspolicyandguidance/browsable/ dh-4098184
23. Department of Health. HSC 2003/010: Updated national guidance on the safe administration of intrathecal chemotherapy. 2003. http://webarchive. nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/ Lettersandcirculars/Healthservicecirculars/DH-4064931
24. National Patient Safety Agency. Rapid Response Report 4: Vinca alkaloid minibags (adult|adolescent units). 2008. http://www.nrls.npsa.nhs.uk/resources/ type/alerts/?entryid45=59890&p=2
25. Department of Health HSC 2008/001: Updated national guidance on the safe administration of intrathecal chemotherapy. 2008. http://webarchive. nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandstatistics/ lettersandcirculars/healthservicecirculars/dh-086870
26. National Patient Safety Agency. Seven Steps to Patient Safety. 2004. http://www.nrls.npsa.nhs.uk/resources/?entryid45=59787
27. NHS Commissioning Board. Transfer of patient safety functions to the NHS Commissioning Board. 2012. Available online at http://www.commissioningboard. nhs.uk/2012/05/31/npsa-transfer/
28. National Patient Safety Agency. NRLS Quarterly Data Workbook up to March. 2012. http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-data- summaries/?entryid45=135152
29. Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013. http://www.health.org.uk/publications/the- measurement-and-monitoring-of-safety/
30. Catalogue of blunders that led to death. BBC 2001. http://news.bbc.co.uk/ 1/hi/health/1284244.stm
31. Berwick DM. Not again! Preventing errors lies in redesign not exhortation. BMJ 2001;322:247-8. (Pubitemid 32178543)
32. Ahmed Z, McLeod M, Barber N, et al. The use and functionality of electronic prescribing systems in English acute NHS trusts: a cross-sectional survey. PLoS ONE 2013;8:e80378.
33. Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood) 2011;30:559-68.
34. World Health Organization. Learning from Error-video and booklet. 2008. http://www.who.int/patientsafety/education/vincristine-download/en/
35. Reason J. Patient safety, human error, and Swiss cheese. Interview by Karolina Peltomaa and Duncan Neuhauser. Qual Manag Health Care 2012;21:59-63.
36. Thomas MJ, Schultz TJ, Hannaford N, et al. Mapping the limits of safety reporting systems in health care-what lessons can we actually learn? Med J Aust 2011;194:635-9.
37. Panesar SS, Cleary K, Sheikh A. Reflections on the National Patient Safety Agency's database of medical errors. J R Soc Med. 2009;102:256-8.