A hospital quality improvement committee is reviewing several patient safety incidents that occurred over the past month. Match each clinical safety incident to its most appropriate error classification.
- A pharmacist detects and intercepts an incorrectly prescribed high-dose chemotherapy order before the drug reaches the patient.Near miss
- An automated medication dispensing cabinet is systematically stocked with look-alike vials in adjacent bins.Latent error
- A patient undergoes a surgical procedure on the wrong extremity due to a failure to perform a preoperative time-out.Sentinel event
- A physician accidentally selects the wrong dosage from a drop-down menu while placing an order, directly leading to an adverse drug event.Active error
Answer
The correct matches are: The intercepted chemotherapy order is a Near miss. The dispensing cabinet stocking issue is a Latent error. The wrong-site surgery is a Sentinel event. The incorrect drop-down dosage selection is an Active error.
Each clinical incident corresponds to a specific patient safety classification. A near miss is an error intercepted prior to patient impact. A latent error is a systemic vulnerability (like poor storage design). A sentinel event is a devastating, typically preventable outcome (like wrong-site surgery) requiring immediate investigation. An active error is a direct human mistake at the point of care.
Step-by-Step Solution
Key Concept
Classification of patient safety incidents and medical errors