218: Prescribed Drug Interaction Issue*

Node Prescribed Drug Interaction Issue*

*This node is for descriptive purposes only. Code only to Personnel Performance; Individual Issue (#213).

Definition/Typical Issues

Was the individual taking prescribed medications that affected his or her job performance?

Note 1: This node addresses inadvertent prescription drug interactions. Drug and alcohol abuses are addressed by the Drug/Alcohol Abuse (#222) node.

Note 2: The Personnel Performance Issue; Individual Issue (#213) node should only be used when the problem is isolated to one individual. If other personnel have difficulty performing the same task under similar circumstances, then other portions of the Root Cause Map™ should be used to code the issue.

Note 3: There should be management systems in place to detect and correct most (if not all) individual performance issues BEFORE an incident occurs. Therefore, the failure or absence of the management systems should be coded as well.

Note 4: Consider coding under the Personnel Hiring Issue (#209) node because there should be management controls to ensure that employees possess the required job capabilities prior to being hired. Also consider coding under the Supervision During Work Issue (#192) or Detection of Individual Performance Issue (#212) nodes because supervision should detect this problem.

Note 5: Code as Personnel Performance Issue; Individual Issue (#213) only. The 10 nodes beneath Individual Issue (#213) are included to provide the investigator with an understanding of the types of problems that might be categorized as Personnel Performance Issue; Individual Issue (#213). However, the investigator should NOT include these cause nodes in the investigation report.

Examples

Example 1

  • An operator was prescribed a medication that caused drowsiness. During a tank transfer, he lost track of time and the tank overflowed.

Example 2

  • A quality assurance technician was prescribed a drug that interacted with another medication he was taking. It caused him to become dizzy. As a result, he fell down while going up some stairs.

Typical Recommendations

  • Encourage personnel to report personnel performance problems that they observe.

Cross-References

Version 10 Element(s)
Node ID Node Name
215 Personal/Medication Problems

 

Maritime Element(s)
Node ID Node Name
255 Personal Medication Use/Abuse
Back to top