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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; (2014) Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids. BMJ Quality & Safety , 23 (9) pp. 765-772. 10.1136/bmjqs-2013-002572. Green open access

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Abstract

Catastrophic errors in healthcare are rare, yet the consequences are so serious that where possible, special procedures are put in place to prevent them. As systems become safer, it becomes progressively more difficult to detect the remaining vulnerabilities. Using inadvertent intrathecal administration of vinca alkaloids as an example, we investigated whether analysis of incident report data describing low-harm events could bridge this gap.

Type: Article
Title: Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids
Open access status: An open access version is available from UCL Discovery
DOI: 10.1136/bmjqs-2013-002572
Publisher version: http://dx.doi.org/10.1136/bmjqs-2013-002572
Language: English
Additional information: This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/
Keywords: Incident reporting, Medication safety, Risk management
UCL classification: UCL
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Life Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Life Sciences > UCL School of Pharmacy
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Life Sciences > UCL School of Pharmacy > Practice and Policy
URI: https://discovery.ucl.ac.uk/id/eprint/1425064
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