Latest / Lean Blog by Mark Graban
Outcome Bias, Near Misses, and Two Vials of Vecuronium
tl;dr: A nurse nearly administered vecuronium instead of vancomycin but caught the error before it reached the patient. The near miss shows how outcome bias and underreporting distort safety data: when leaders see only errors that cause harm, they may blame individuals instead of recognizing system hazards that other nurses encountered–and stopped–without anyone ever learning from them. In a busy emergency department in the early 2000s, nurses were mixing some of their own medications. One […] The post Outcome Bias, Near Misses, and Two Vials of Vecuronium by Mark Graban…
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