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Difficulty: MediumMedical Errors and Malpractice

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

  • Active errorAn emergency department physician inadvertently intubates a patient's esophagus instead of the trachea during a code.
  • Latent errorA hospital's central supply routinely places similar-appearing vials of epinephrine and local anesthetics in adjacent, poorly lit storage bins.
  • Near missA resident mistakenly orders 50 mg of intravenous morphine instead of 5 mg, but the ward pharmacist intercepts the order before it is dispensed.
  • Sentinel eventA patient admitted to the inpatient psychiatric unit for severe depression commits suicide by hanging in the hospital bathroom.

Answer

Active error pairs with the physician intubation mistake. Latent error pairs with the medication storage flaw. Near miss pairs with the intercepted morphine order. Sentinel event pairs with the inpatient suicide.
Patient safety events must be categorized to guide the appropriate level of investigation and quality improvement. Active errors are direct actions by operators (sharp end). Latent errors are systemic vulnerabilities built into processes (blunt end). Near misses are errors caught before patient contact, providing free lessons for system improvement. Sentinel events involve catastrophic harm or death, requiring immediate mandatory reporting and root cause analysis.

Step-by-Step Solution

1
Analyze the scenario regarding the emergency department physician.
The physician performs an incorrect procedural action with immediate consequences.
This identifies the event as an active error, occurring at the sharp end of patient care.
2
Evaluate the scenario involving central supply and medication storage.
This is a systemic, structural issue that creates dangerous conditions for future mistakes.
This characterizes a latent error, which occurs at the blunt end of healthcare delivery.
3
Review the scenario where a pharmacist intercepts a lethal dose of morphine.
The error was caught before reaching the patient.
Because no harm occurred due to interception, this defines a near miss or close call.
4
Assess the scenario involving an inpatient suicide.
This is a severe, unexpected outcome involving death in a healthcare setting.
Catastrophic events that require immediate investigation (root cause analysis) are classified as sentinel events.

Key Concept

Classification of Medical Errors and Adverse Events
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Topics

Medical Errors and Malpractice

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