During a monthly morbidity and mortality conference, a healthcare organization's patient safety officer reviews several recent clinical incidents to identify systemic improvement opportunities. Match each incident summary to its most accurate error taxonomy classification.
- A physician prescribes an excessively high dose of intravenous heparin. The clinical pharmacist identifies the anomaly during review, and the order is corrected before administration.Near miss (Close call)
- A patient develops life-threatening anaphylaxis to a newly initiated biologic therapy despite appropriate indication, correct weight-based dosing, and strict adherence to administration protocols.Unpreventable adverse event
- A nurse intends to administer intravenous famotidine but inadvertently picks up and administers a vial of similarly packaged fosphenytoin from the medication drawer.Active execution error (Slip)
- A patient receives the wrong blood product because a recent hospital software update introduced a hidden glitch that misaligns patient identification numbers on printed transfusion labels.Latent system vulnerability
Answer
The intercepted heparin order is a near miss; the anaphylaxis to correctly dosed biologic therapy is an unpreventable adverse event; the inadvertent administration of the wrong medication due to packaging is an active execution error; and the software glitch causing misaligned labels is a latent system vulnerability.
Each incident correctly aligns with established patient safety taxonomy. A near miss is an intercepted error. An unpreventable adverse event occurs despite appropriate care. A slip is a sharp-end execution failure, and a latent vulnerability is a blunt-end system defect.
Step-by-Step Solution
Key Concept
Accurate classification of patient safety incidents requires distinguishing between active errors (sharp end), latent vulnerabilities (blunt end), near misses, and unpreventable adverse events.