Mivacron Analysis

Traditionally, error analysis has focused on identifying the cause. However, one basic finding from research is that accidents in complex systems only occur through the concatenation of multiple small factors or failures, each necessary but only jointly sufficient to produce the accident. Often these small failures or vulnerabilities are present in the organization long before a specific incident is triggered. All complex systems contain such latent factors or failures, but only rarely do they combine to create the trajectory for an accident.

A combination of latent failures occurring simultaneously created the conditions for the Mivacron accident

• There was poor communication throughout the institution about the trial of a new paralyzing agent.
• Alphabetical storage of medications allowed for similar drugs to get confused
• Previously, there was only one medicine that was foil wrapped (Flagyl).
• It was difficult to see the name of either product.
• Stickers should have been placed on the outside of the bags. This was misunderstood and not done.