Medical Misadministrations and “Peeping Tom” Research

Abstract

From the inside it looks like “random human error,” could looking in from the outside produce a different view? In order to answer that question, the Nuclear Regulatory Commission constructed a database of information on radiopharmaceutical misadministrations. Counts, sorts, and listings of data indicated that looking through the window provided by that database gave a usefully different view of events associated with radiopharmaceutical misadministrations. The addition of data fields to “widen” and “clean” that window made it easier to look through it and to see apparent “non-randomness” that might pinpoint a place where human factors intervention could have beneficial impact.