A root cause analysis is being conducted after an intensive care unit patient inadvertently received a paralyzing agent instead of a sedative, resulting in a sentinel event. The investigation reveals multiple contributing factors that aligned to cause the error, conceptualized by the 'Swiss cheese' model of accident causation. Match each specific contributing factor identified in this case (Left) with its correct error classification in patient safety terminology (Right).
- The nurse bypassed the barcode medication administration scanner to administer the drug.Active error at the sharp end
- Look-alike vecuronium and midazolam vials were stored in adjacent automated dispensing cabinet bins.Latent error: Physical environment and design
- Hospital administration mandated consecutive 12-hour shifts due to chronic nursing shortages.Latent error: Staffing and workforce management
- The institution's standard operating procedure permitted dispensing cabinet overrides without pharmacist review.Latent error: Organizational protocol and culture
Answer
Bypassing the scanner is an active error at the sharp end. Storing look-alike vials together is a latent error of physical environment and design. Mandating consecutive shifts is a latent error of staffing and workforce management. Permitting overrides without review is a latent error of organizational protocol and culture.
In root cause analysis, errors are divided into active errors (immediate acts by frontline workers at the 'sharp end') and latent errors (underlying systemic, organizational, or environmental flaws at the 'blunt end' that facilitate active errors). By matching each specific factor to its correct category, quality improvement teams can target interventions appropriately.
Step-by-Step Solution
Key Concept
Classification of active errors (sharp end) versus latent errors (blunt end) in Root Cause Analysis