Propofol Analysis

     Change and the risk of failure are an inevitable aspect of production where danger is a pervasive and accepted cost of doing business. We build defenses against failure and may grow complacent as continuous production pressures dominate attention. Defenses erode over time while danger is masked by the absence of bad events and production pressures and incremental changes drive us to the margins of safety. The gradual breakdown of defenses over time that increases the risk of adverse events can be described as a drift toward failure. Often, we don’t recognize the drift until an event occurs. Near misses alert us to the proximity of danger; sharing this information is one way to avert disaster.

This drift toward failure contributed to the actions and decisions that led to the shift from pain control to anesthesia level of propofol include:

• Pressure from the family to alleviate the extreme pain.
• Staff involved had experience with propofol with a different patient at another hospital who was subsequently treated at the featured hospital with successful results.
• Propofol had been added to the formulary recently.
• Level of drug increased to anesthetic levels over the night as agitation worsened.