Match each clinical incident summary with its most appropriate classification in the medical error and patient safety taxonomy.
- Active errorA frontline provider accidentally programs an incorrect infusion rate on an IV pump due to fatigue.
- Latent errorAn electronic health record defaults to adult dosing for pediatric patients, creating a systemic vulnerability.
- Near missA pharmacist intercepts a medication order that would have caused a severe drug-drug interaction before it reaches the patient.
- Sentinel eventA patient experiences unexpected death due to an ABO-incompatible blood transfusion during an elective surgery.
- Unpreventable adverse eventA patient with no known allergies develops Stevens-Johnson syndrome after being treated with a standard antibiotic regimen.
Answer
Proper classification requires identifying the point of system failure (sharp vs. blunt end) and the ultimate outcome (harm vs. no harm).
Each scenario aligns perfectly with standard patient safety definitions: active errors happen at the frontline, latent errors are foundational system flaws, near misses are intercepted errors, sentinel events cause severe unexpected harm, and unpreventable adverse events happen despite standard care.
Step-by-Step Solution
Key Concept
Classification of Medical Errors and Adverse Events