Multiple Latent Failures Align to Allow a Serious Drug Interaction to Harm a Patient

ISMP Medication Safety Alert 

In This Article

Abstract and Introduction


Whenever ISMP assists hospitals with a root cause analysis or conducts its own investigation of an adverse event, we inevitably uncover numerous precipitating latent failures (see definition in box at the end of the article) that led to the actual event. Similar to dominos that require perfect alignment in order to collapse in a series, latent failures also must align perfectly for an event to occur and go unnoticed. A serious drug interaction between simvastatin and ketoconazole that recently harmed a patient is an example of the perfect alignment of latent failures and its role in adverse events. As you read the details of the event, notice how the drug interaction may have been avoided or captured at numerous points during the patient's medical care had it not been for the series of latent failures that almost seemed to conspire against the patient and healthcare providers.


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