In 1982, 31 million bottles of Tylenol were recalled after seven deaths from cyanide poisoning. After an investigation, higher than lethal doses of cyanide were found to have been inserted into bottles of Extra-Strength Tylenol capsules in retail stores in the Chicago area. Tylenol’s manufacturer, Johnson & Johnson, immediately took action and recalled all Tylenol products.
Although the reason for the poisoning is unclear – the suspect has still not been caught, though interest in the case has recently been revived – what was clear is that the ability to tamper with a product in such a malicious way without the tampering being evident contributed to the deaths. As a result of this issue, capsules (which are much easier to insert foreign objects into than solid pills) decreased in use, and tamper-evident packaging became used for many products.
Although the manufacturing and packaging process were not implicated in the poisonings (the adulterated packages were from different plants, but all came from stores within the Chicago area), there was concern that Tylenol would never again be popularly accepted. However, Johnson and Johnson’s quick and effective action in the immediate recall of all products and public relations campaigns to urge people not to use products until the issue had been resolved has been considered a playbook on how to conduct an effective recall and is believed to have directly contributed to the resurgence in the popularity of Tylenol shortly after the issue. (See “How Effective Public Relations Saved Johnson and Johnson“.)
Even though this case hasn’t been resolved, and the killer still remains unknown, it is possible to examine the issue with a Cause Map. Because this case has stretched over many years, a timeline can help to sort through information. The outline contains the many impacts to the goals related to the issue, and the Cause Map sorts through causes – both “good” and “bad” – related to the issue. Solutions implemented to decrease the ability to tamper with consumer products are also noted.