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Difficulty: HardClassification of Medical Errors and Adverse Events

A 70-year-old man is admitted to the intensive care unit with a large acute intraparenchymal hemorrhage. The admitting resident is rapidly placing admission orders using the hospital's standard electronic order set for ICU admissions. The resident is aware that deep vein thrombosis (DVT) is a major risk for immobilized ICU patients. Following the standard ICU admission algorithm, the resident selects "subcutaneous heparin" for DVT prophylaxis. The resident does this intentionally, believing it is the correct protocol for all immobilized patients, but fails to recognize that acute intracranial bleeding is an absolute contraindication to pharmacologic anticoagulation. The patient receives the heparin and subsequently suffers neurological deterioration due to hematoma expansion. Which of the following best classifies the cognitive mechanism of the resident's prescribing error?

  1. Rule-based mistakeAnswer
  2. B
    Knowledge-based mistake
  3. C
    Skill-based slip
  4. D
    Memory-based lapse
  5. E
    Routine violation

Answer

The resident's error is best classified as a rule-based mistake.
The correct classification is a rule-based mistake. In human error taxonomy, a 'mistake' occurs when the intended action goes exactly as planned, but the underlying plan itself is flawed. A 'rule-based' mistake specifically happens when a provider applies a generally correct clinical rule (e.g., 'immobilized ICU patients require DVT prophylaxis') but fails to recognize that the specific patient context makes the rule inappropriate or contraindicated (e.g., an active intracerebral hemorrhage). The resident did not make a physical error in ordering (slip) or forget to order (lapse), nor were they in a completely novel situation requiring first-principles problem-solving (knowledge-based mistake).

Step-by-Step Solution

1
Analyze the nature of the error in the clinical vignette.
The resident intentionally ordered heparin based on a general rule for ICU patients, missing the contraindication of active bleeding.
Determining the intent and awareness of the provider is necessary to accurately classify the human error.
2
Differentiate between an execution error and a planning error.
The execution was correct (the resident ordered exactly what they intended to order), but the plan was flawed. This rules out execution failures (slips and lapses).
Slips and lapses are execution failures; mistakes are planning failures.
3
Determine the type of planning error (mistake).
The resident applied a familiar 'if-then' rule inappropriately to an exception, rather than problem-solving in a completely novel situation.
Applying a well-known rule to the wrong situation defines a rule-based mistake, distinguishing it from a knowledge-based mistake.

Key Concept

According to James Reason's taxonomy of human error, active errors are classified into slips (execution failures), lapses (memory failures), mistakes (planning failures), and violations (intentional deviations). Mistakes are further divided into rule-based (misapplying a known rule) and knowledge-based (failing to problem-solve accurately in novel situations).
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Topics

Classification of Medical Errors and Adverse Events

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