Question

Difficulty: EasyRoot Cause Analysis and Error Investigation

Match each clinical scenario to its correct patient safety classification.

  • A bedside nurse mistakenly programs an intravenous infusion pump to deliver 100 mL/hr instead of the ordered 10 mL/hr.Active error
  • A hospital pharmacy stocks two different high-alert medications that have nearly identical manufacturer packaging in adjacent bins.Latent error
  • A patient undergoes an invasive orthopedic procedure on the incorrect extremity, resulting in permanent loss of function.Sentinel event
  • A physician prescribes a medication to which the patient has a documented allergy, but the dispensing pharmacist identifies the error and halts the order.Near miss

Answer

The infusion pump error is an Active error; the identical packaging is a Latent error; the wrong-site surgery is a Sentinel event; the intercepted medication order is a Near miss.
Each scenario accurately matches a distinct category within the patient safety error taxonomy based on its origin, proximity to the patient, and ultimate outcome.

Step-by-Step Solution

1
Analyze the infusion pump programming scenario.
Identified as occurring at the frontline of care delivery.
Mistakes made at the point of contact between a human and the system represent an active error.
2
Analyze the identical medication packaging scenario.
Identified as a systemic vulnerability created away from direct patient care.
System or design flaws that predispose workers to make mistakes are classified as latent errors.
3
Analyze the wrong-site surgery scenario.
Identified as an outcome with severe, permanent harm.
Events involving death or serious physical/psychological injury meet the criteria for a sentinel event.
4
Analyze the intercepted allergy prescription scenario.
Identified as a potential adverse event that was caught before reaching the patient.
Unsafe situations that are intercepted before causing patient harm are classified as near misses.

Key Concept

Classification of Medical Errors and Patient Safety Events
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