Match each of the following clinical incident scenarios to the most appropriate patient safety event classification category.
- A 28-year-old man with no documented medical history receives appropriately dosed prophylactic cefazolin prior to hernia repair and rapidly develops anaphylactic shock.Unpreventable adverse event
- A pediatric patient is prescribed an oral suspension of amoxicillin, but the pharmacy technician prepares it at ten times the intended concentration; the bedside nurse notices the discrepancy before administration.Near miss (Close call)
- A 55-year-old woman undergoes a total abdominal hysterectomy; due to a bypassed surgical counting protocol, a laparotomy pad is inadvertently left inside her abdomen, requiring an emergent second operation.Sentinel event
- A 70-year-old man with known severe asthma is incorrectly prescribed a nonselective beta-blocker for hypertension, leading to a severe asthma exacerbation requiring hospitalization.Preventable adverse event
Answer
The cefazolin-induced anaphylaxis is an unpreventable adverse event. The intercepted medication error is a near miss. The retained laparotomy pad is a sentinel event. The asthma exacerbation caused by a contraindicated beta-blocker is a preventable adverse event.
The correct matches rely on identifying whether an error occurred, whether it reached the patient, and the severity of the outcome. A near miss is an error intercepted before patient harm. A preventable adverse event involves harm caused by an error (e.g., contraindicated drug). An unpreventable adverse event involves harm from appropriate care (e.g., first-time allergic reaction). A sentinel event involves unexpected death or severe physical/psychological harm, strictly including 'never events' like retained surgical items.
Step-by-Step Solution
Key Concept
Classification of patient safety events depends on whether an error occurred, whether the error reached the patient, and the severity of the resulting harm.