Examkin

Question

Difficulty: MediumPatient Safety and Quality Improvement

Match each clinical scenario or hospital practice to the most appropriate patient safety error classification.

  • A physician prescribes cephalexin to a patient with a documented severe anaphylactic allergy to cephalosporins, but the pharmacy's computerized order entry system generates a hard stop alert, allowing the pharmacist to cancel the order before dispensing.Near miss (Close call)
  • A resident physician, experiencing severe fatigue at the end of a 28-hour shift, miscalculates the weight-based dosage of intravenous gentamicin for a pediatric patient and administers the incorrect dose.Active error
  • A hospital purchases two different high-risk intravenous medications that have nearly identical packaging and stores them in adjacent, poorly lit medication dispensing bins.Latent error
  • A patient scheduled for a left-sided elective inguinal hernia repair mistakenly undergoes surgery on the right side, resulting in unnecessary anatomical alteration and a required second surgery.Sentinel event

Answer

The correct pairings classify the intercepted error as a near miss, the direct provider mistake as an active error, the systemic storage flaw as a latent error, and the wrong-site surgery as a sentinel event.
Appropriate patient safety event classification requires identifying the proximity of the error to the patient (active vs. latent), whether the error reached the patient (near miss), and the severity of the ultimate outcome (sentinel event).

Step-by-Step Solution

1
Evaluate whether the error reached the patient and caused harm.
The intercepted cephalexin prescription did not reach the patient, classifying it as a near miss.
Errors caught prior to patient exposure represent successful systemic safety barriers rather than actual adverse events.
2
Differentiate between immediate human failures and underlying system design flaws.
The resident's miscalculation is a point-of-care failure (active error), while the similar packaging in a dark bin is a systemic flaw (latent error).
Active errors occur at the sharp end of practice, whereas latent errors represent blunt-end vulnerabilities designed into the system.
3
Identify the severity and categorization of the wrong-site surgery.
Wrong-site surgery is categorized as a sentinel event.
Events resulting in catastrophic, preventable harm (like wrong-site surgery or infant abduction) are universally defined by regulatory bodies as sentinel events.

Key Concept

Patient Safety Error Classifications
Rate this question

Topics

Patient Safety and Quality Improvement

More questions from this topic