Dispensing errors in high-risk intravenous preparation have been studied in the past, but it is unlikely that these studies have detected these errors because of the inherent limitations of the detection methods used. Research on preparation errors using more sensitive methods is therefore urgently needed to establish the extent to which pharmacy preparation practices may be error-prone, and to allow reliable evaluation of the impact of mitigation strategies. Widespread practice changes in Canadian oncology pharmacies are necessary, and are currently underway.
In 1986, Bovine Spongiform Encephalopathy (BSE) was identified in the United Kingdom. Millions of BSE-infected cows and were slaughtered and over 150 people contracted variant-Creutzfeldt Jakob Disease (vCJD), an inevitably fatal human form of BSE. The purpose of this study was to test the ability of Rasmussen's (1997) risk management framework to explain how and why BSE (and later vCJD) entered the human and animal food supply from 1986 to 1996. This study represents the first test of the ability of Rasmussen's framework to explain how and why accidents occur in the food production domain. Using a case study methodology, this study investigates how well the evidence of the case study supports the framework's seven predictions of how and why accidents occur in complex socio-technical systems. All seven of the predictions were supported by the evidence.
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