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    Brain sample damage highlights crucial role of risk management

     Internal investigations are underway at McLean Hospital after a freezer malfunction at a brain bank damaged about one-third of a collection of autism samples.
    ESSDRAS M SUAREZ/GLOBE STAFF
    Internal investigations are underway at McLean Hospital after a freezer malfunction at a brain bank damaged about one-third of a collection of autism samples.

    Some might choose to call the “freezer malfunction” purported to have “severely damaged one-third of the world’s largest collection of autistic brains” a “glitch,” while others might term it “the perfect storm of alarm and thermostat failure and the concentration of samples,” so as to suggest “foul play” (“Brain sample damage hurts researchers,” Page A1, June 11). Yet, to conclude that human error was not the cause of the horrific consequence would be to abrogate responsibility where responsibility is due.

    After all, machines are manufactured by humans who are responsible for assuring their reliability prior to their use in the workplace. In turn, humans in the workplace are responsible for assuring that machines function reliably through time.

    Obviously, the tragic event at the Harvard Brain Tissue Resource Center, at McLean Hospital, involved some type of human error or errors that might have been prevented or made less likely.

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    The latter could best be done through a carefully designed system of risk assessment and risk management. Risk management is a process designed to identify, assess, and prioritize levels of risk with the ultimate goal of eliminating or minimizing their negative impact.

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    Hopefully, as a part of the investigation at McLean, those responsible for monitoring and assuring the future safety of the brain bank will consult the National Institute of Science and Technology on how best to proceed in developing a better system of risk management than currently exists.

    David L. Maxwell

    Marshfield

    The writer is professor emeritus in the department of communication sciences and disorders at Emerson College.