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Difficulty: MediumClassification of Medical Errors and Adverse Events

A 61-year-old man with metastatic non-small cell lung cancer presents to an outpatient oncology clinic for a scheduled chemotherapy infusion. The oncologist reviews the patient's chart and enters an order for intravenous cisplatin. Ten minutes later, the clinical pharmacist reviewing the order notes that the patient's comprehensive metabolic panel, drawn that morning, shows a serum creatinine of 2.62.6 mg/dL, which is a significant increase from his baseline of 1.01.0 mg/dL one month ago. Recognizing that cisplatin is highly nephrotoxic and contraindicated in the setting of acute kidney injury, the pharmacist immediately pages the oncologist. The oncologist acknowledges the oversight, cancels the cisplatin order, and prescribes an appropriate, non-nephrotoxic alternative regimen. The patient receives the alternative chemotherapy without any complications. Which of the following best classifies this safety event?

  1. A
    Active error
  2. B
    Preventable adverse event
  3. Near missAnswer
  4. D
    Sentinel event
  5. E
    Unpreventable adverse event

Answer

Near miss
The safety event described is a near miss (also known as a close call). A near miss occurs when a medical error is committed but is intercepted before it reaches the patient, thereby preventing potential harm. In this scenario, the oncologist made an error by ordering cisplatin for a patient with acute kidney injury. However, the system's safety net—specifically, the clinical pharmacist's review—successfully identified and stopped the error before the nephrotoxic drug was administered.

Step-by-Step Solution

1
Identify the initial error made in the clinical scenario.
The oncologist prescribed cisplatin, a nephrotoxic drug, to a patient with acute kidney injury.
Recognizing the presence of an error is the first step in classifying the safety event.
2
Trace the path of the error to determine if it reached the patient.
The clinical pharmacist intercepted the order and contacted the physician, resulting in the cancellation of the medication.
Whether an error reaches the patient differentiates a near miss from an adverse event.
3
Assess the clinical outcome for the patient.
The patient received an alternative medication and suffered no harm.
The presence and severity of harm determine if an event is a preventable adverse event or a sentinel event.
4
Classify the event based on the findings.
An error that is intercepted before reaching the patient is defined as a near miss.
Applying standard patient safety terminology provides the final classification.

Key Concept

A near miss (or close call) is a patient safety event where an error is committed but intercepted before it reaches the patient, thereby preventing any harm.
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Topics

Classification of Medical Errors and Adverse Events

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