We Have Newton on a Retainer: Reductionism When We Need Systems Thinking

摘要

Something must have gone terribly wrong when a 16-year-old patient died after a nurse accidentally administered a bag of epidural analgesia by the intravenous route instead of the intended penicillin. What was it? We typically want to find the broken parts, fix them, remove them, and make sure that they can't contribute to failure again. The root cause analysis (RCA) described by Smetzer et al. in this issue of the Journal does precisely that. As a starting point, the RCA identified four proximate causes of the error: (1) availability of an epidural medication in the patient's room before it was prescribed or needed, (2) selection of the wrong medication from a table, (3) failure to place an identification band on the patient, which was required to utilize a point-of-care bar-coding system, and (4) failure to employ available bar-coding technology to verify the drug before administration.