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Difficulty: EasyPatient Safety and Quality Improvement

A 58-year-old man is admitted to the hospital for treatment of lower extremity cellulitis. He has a known allergy to cephalosporins that causes severe hives. During the intake process, the admitting nurse documents this allergy in the free-text triage note. However, the nurse fails to enter it into the formal electronic allergy module because the entry field is hidden at the very bottom of a secondary screen that requires excessive scrolling, which is a widely recognized usability issue among the staff. Later, the primary care team prescribes intravenous cefazolin. Because the allergy was not in the structured module, the pharmacy system does not trigger an alert. The patient receives the medication and develops a mild urticarial rash that resolves rapidly with oral diphenhydramine. Which of the following terms best describes the poor electronic health record interface design in this scenario?

  1. Latent errorAnswer
  2. B
    Active error
  3. C
    Sentinel event
  4. D
    Near miss
  5. E
    Slip

Answer

The poorly designed interface is a latent error because it represents a systemic, structural flaw that sets up frontline workers to make mistakes.
The correct answer identifies that the interface design is a latent error. In the 'Swiss Cheese Model' of medical errors, latent errors are hidden, systemic defects built into the organization, software, or workflow (e.g., poor usability, understaffing, confusing protocols). They remain dormant until they align with active errors (mistakes by frontline staff, such as the nurse failing to document in the correct field) to cause an adverse event.

Step-by-Step Solution

1
Analyze the nature of the described problem (the hidden electronic health record field).
The problem is a structural, design-based flaw inherent to the hospital's software system.
Identifying who or what is responsible for the hazard helps categorize the error type.
2
Differentiate between systemic flaws and individual frontline actions in the Swiss Cheese Model of accident causation.
Systemic, underlying flaws are 'latent errors' (or conditions), while mistakes made by the healthcare workers interacting with the system are 'active errors'.
Latent errors are the 'holes' in the defensive layers that allow active errors to propagate and reach the patient.

Key Concept

In patient safety, latent errors are systemic, structural, or environmental design flaws that pre-exist and predispose frontline personnel to make active errors.
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Topics

Patient Safety and Quality Improvement

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