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Difficulty: MediumClassification of Medical Errors and Adverse Events

A 62-year-old man is admitted to the intensive care unit for management of septic shock. He requires a continuous intravenous infusion of norepinephrine. The hospital recently transitioned to a new vendor for smart infusion pumps. The new interface features a touchscreen where the decimal point is located unusually close to the zero digit. While adjusting the medication rate, the bedside nurse intends to program 0.05 mcg/kg/min0.05 \text{ mcg/kg/min} but accidentally inputs 0.5 mcg/kg/min0.5 \text{ mcg/kg/min}.

Additionally, the hospital's clinical engineering department has not yet uploaded the standard pharmacological dose-limit library to the newly deployed pumps. Consequently, the pump does not trigger a hard-stop warning for the excessively high dose. The patient receives the higher dose for 15 minutes, resulting in an acute hypertensive emergency and transient myocardial ischemia before the error is identified and the infusion is paused.

Which of the following terms best classifies the hospital's failure to upload the dose-limit library prior to deploying the new pumps?

  1. A
    Active error
  2. Latent errorAnswer
  3. C
    Near miss
  4. D
    Sentinel event
  5. E
    Unpreventable adverse event

Answer

Latent error
The failure to upload the dose-limit library is a system-level vulnerability that created a hazardous environment, allowing a frontline mistake to reach the patient. In the Swiss Cheese model of accident causation, these underlying organizational, design, or maintenance flaws are known as latent errors. They occur at the 'blunt end' of healthcare and remain dormant until they align with an active human error.

Step-by-Step Solution

1
Analyze the specific component of the scenario being queried.
The question specifically asks about the failure to upload the dose-limit library, not the nurse's mistyping or the patient's clinical outcome.
Accurate classification of medical errors requires distinguishing between the frontline action, the underlying system flaws, and the final patient outcome.
2
Differentiate between sharp-end and blunt-end errors.
The nurse's incorrect data entry is a sharp-end action. The missing software library is a blunt-end, organizational flaw.
Errors occurring at the point of contact with the patient are active errors, while organizational or design flaws are latent errors.
3
Apply the correct terminology to the blunt-end flaw.
System-level vulnerabilities that are built into the care environment and lie dormant are classified as latent errors.
This matches the definition established by patient safety and human factors engineering frameworks.

Key Concept

Latent errors are system-level vulnerabilities (e.g., poor equipment design, incomplete protocols, inadequate staffing) that lie dormant at the 'blunt end' of healthcare and create conditions that allow active errors to cause patient harm.
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Topics

Classification of Medical Errors and Adverse Events

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