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Difficulty: MediumClassification of Medical Errors and Adverse Events

Match each clinical incident summary to the correct classification of human error or violation according to the patient safety error taxonomy.

  • SlipAn attending surgeon intends to select 'Lidocaine 1%' from the automated dispensing cabinet but inadvertently presses the adjacent button for 'Lidocaine 2%' on the touch screen.
  • LapseA hospitalist intends to order a screening lipid panel during a routine admission but completely forgets to enter the order into the electronic health record after being interrupted by an urgent page.
  • Rule-based mistakeAn emergency department resident correctly diagnoses a deep vein thrombosis but prescribes a therapeutic dose of enoxaparin without adjusting for the patient's severe renal impairment.
  • Knowledge-based mistakeA newly graduated physician manages an unfamiliar, complex presentation of a rare autoimmune disorder and prescribes a contraindicated therapy due to insufficient understanding of the condition.
  • Routine violationA scrub technician regularly performs a 1-minute hand wash instead of the mandatory 3-minute surgical scrub, a practice that has become normalized to speed up room turnover.

Answer

Slip matches with the inadvertent button press. Lapse matches with forgetting the order after an interruption. Rule-based mistake matches with failing to adjust the dose for renal impairment. Knowledge-based mistake matches with prescribing contraindicated therapy due to lack of knowledge about a rare disorder. Routine violation matches with the habitual shortening of the mandatory surgical scrub.
Medical errors are classified by their cognitive mechanism. Slips are attentional failures during execution (wrong button). Lapses are memory failures causing omission (forgotten order). Rule-based mistakes occur when a good rule is misapplied or a necessary exception is ignored (missing renal dosing). Knowledge-based mistakes stem from inadequate knowledge in novel situations (rare diseases). Routine violations are deliberate, normalized deviations from protocol (shortened scrubs).

Step-by-Step Solution

1
Analyze skill-based execution failures (Slips vs. Lapses).
Identify the button press as a slip (action failure) and the forgotten order as a lapse (memory omission).
Skill-based errors happen during routine tasks. Slips are observable actions gone wrong, while lapses are internal memory failures.
2
Analyze cognitive planning failures (Rule-based vs. Knowledge-based mistakes).
Identify the missed renal adjustment as a rule-based mistake and the incorrect treatment of the rare disorder as a knowledge-based mistake.
Rule-based mistakes involve applying the wrong 'if-then' rule to a known situation, whereas knowledge-based mistakes arise from a complete lack of information in a novel scenario.
3
Identify deliberate procedural deviations (Violations).
Identify the shortened hand scrub as a routine violation.
Unlike errors, violations are intentional acts. Because this shortcut has become normalized in the unit to save time, it classifies as a routine violation.

Key Concept

The human factors classification of medical errors distinguishes between skill-based errors (slips and lapses), cognitive mistakes (rule-based and knowledge-based), and intentional deviations (violations).
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Topics

Classification of Medical Errors and Adverse Events

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