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Difficulty: HardClassification of Medical Errors and Adverse Events

A 68-year-old man is admitted to the medical intensive care unit (ICU) with a massive pulmonary embolism. He is rapidly stabilized and started on a continuous unfractionated heparin infusion. The hospital recently transitioned to a new electronic health record (EHR) system.

During the transition of care from the emergency department (ED), the ED physician provides a verbal sign-out but forgets to mention that the patient's baseline platelet count is 45,000/mm345,000/\text{mm}^3 due to chronic liver cirrhosis. The ICU resident, anchoring on the diagnosis of pulmonary embolism, assumes all baseline laboratories are within normal limits and continues the heparin protocol without independently verifying the platelet count.

Two days later, the patient develops a spontaneous intracranial hemorrhage. An institutional review committee analyzes the event and notes that the new EHR lacks both a standardized handoff tool and an automated alert for anticoagulant orders in the setting of severe thrombocytopenia.

Which of the following accurately classifies the specific sequence of failures in this scenario?

  1. The EHR missing an automated alert is a latent error; the ED physician's forgotten sign-out is a skill-based lapse; the ICU resident continuing heparin without checking contraindications is a rule-based mistakeAnswer
  2. B
    The EHR missing an automated alert is an active error; the ED physician's forgotten sign-out is a knowledge-based mistake; the ICU resident continuing heparin without checking contraindications is a skill-based slip
  3. C
    The EHR missing an automated alert is a latent error; the ED physician's forgotten sign-out is a rule-based mistake; the ICU resident continuing heparin without checking contraindications is a skill-based lapse
  4. D
    The EHR missing an automated alert is a cognitive bias; the ED physician's forgotten sign-out is an active error; the ICU resident continuing heparin without checking contraindications is a sentinel event
  5. E
    The EHR missing an automated alert is a systemic violation; the ED physician's forgotten sign-out is a latent error; the ICU resident continuing heparin without checking contraindications is an unpreventable adverse event

Answer

The EHR missing an automated alert is a latent error; the ED physician's forgotten sign-out is a skill-based lapse; the ICU resident continuing heparin without checking contraindications is a rule-based mistake
According to human error taxonomy, the sequence is classified by the nature of each failure. The absence of an automated EHR alert and standardized handoff tool represents a system vulnerability built into the environment, which is a latent error (blunt end). The ED physician intending to give a complete sign-out but forgetting the platelet count is a memory failure during a routine task, known as a skill-based lapse (active error). The ICU resident continuing the heparin without verifying baseline laboratories involves applying a valid treatment rule (heparin for PE) to the wrong situation due to a failure to gather complete information, which defines a rule-based mistake (active error).

Step-by-Step Solution

1
Analyze the EHR deficiencies (no handoff tool, no automated alert).
Identified as blunt-end system vulnerabilities.
Conditions designed into the system that predispose to active errors are classified as latent errors.
2
Analyze the ED physician's forgotten sign-out.
Identified as a memory failure during a routine task.
Memory failures occurring at the sharp end of patient care are classified as skill-based lapses.
3
Analyze the ICU resident's decision to continue heparin.
Identified as applying a good treatment rule (heparin for PE) to the wrong situation due to incomplete information gathering.
Applying a clinical rule without verifying the necessary preconditions (checking for contraindications) constitutes a rule-based mistake.

Key Concept

Classification of errors differentiates between latent errors (system vulnerabilities) and active errors (sharp-end human failures), which are further divided into skill-based errors (slips and lapses) and mistakes (rule-based and knowledge-based).
Estimated Time:2m 0s
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Topics

Classification of Medical Errors and Adverse Events

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