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Difficulty: Very hardClassification of Medical Errors and Adverse Events

A 60-year-old man presents to the emergency department with severe, crushing chest pain that began 45 minutes ago. An initial electrocardiogram reveals ST-segment elevations in leads II, III, and aVF. The emergency physician diagnoses an acute inferior myocardial infarction. During the brief history, the patient mentions taking sildenafil 12 hours prior for erectile dysfunction. The physician, focusing on the acute coronary syndrome algorithm, immediately orders sublingual nitroglycerin and aspirin. The nurse administers the medications. Within minutes, the patient develops profound hypotension and cardiogenic shock. He requires emergent endotracheal intubation, initiation of vasopressors, and placement of an intra-aortic balloon pump. He survives but requires a 14-day intensive care unit stay. A subsequent hospital review reveals that the electronic health record drug-drug interaction alert system had been temporarily disabled by the information technology department for a system update without notifying the clinical staff. According to the taxonomy of medical errors and patient safety, which of the following best classifies the elements of this incident?

  1. The disabled electronic health record alert system is a latent error, and the patient's resulting cardiogenic shock is a sentinel event.Answer
  2. B
    The administration of nitroglycerin following recent sildenafil use is an unpreventable adverse event because it is mandated by acute coronary syndrome protocols.
  3. C
    The physician's failure to consider alternative diagnoses beyond myocardial infarction is a latent error driven by premature closure.
  4. D
    The incident is classified as a near miss, and the software vulnerability should be investigated prospectively using a Failure Mode and Effects Analysis.
  5. E
    The adverse outcome is an active error primarily resulting from an incomplete transition of care during patient triage.

Answer

The disabled electronic health record alert system is a latent error, and the patient's resulting cardiogenic shock is a sentinel event.
The disabled electronic health record alert is a latent error, which is a system-level vulnerability located at the 'blunt end' of healthcare delivery. When the physician missed the medication history (an active error at the 'sharp end'), this latent error allowed the mistake to reach the patient. The resulting profound cardiogenic shock required life-saving interventions (endotracheal intubation, vasopressors, intra-aortic balloon pump). This meets The Joint Commission's criteria for a sentinel event, defined as an event resulting in death, permanent harm, or severe temporary harm.

Step-by-Step Solution

1
Analyze the systemic factors contributing to the error.
The IT department's decision to disable the electronic health record alert system without clinical notification created a hidden vulnerability.
Identifying 'blunt end' system failures is required to define latent errors.
2
Evaluate the clinical outcome based on patient safety event definitions.
The patient suffered cardiogenic shock requiring intubation and an intra-aortic balloon pump.
The Joint Commission defines any patient safety event resulting in severe temporary harm and requiring life-saving intervention as a sentinel event.

Key Concept

In patient safety taxonomy, latent errors are system-level vulnerabilities that lie dormant until combined with an active error. A sentinel event is an adverse event that results in death, permanent harm, or severe temporary harm requiring life-saving intervention.
Estimated Time:1m 30s
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Classification of Medical Errors and Adverse Events

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