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Difficulty: MediumClassification of Medical Errors and Adverse Events

A 31-year-old woman is admitted to the inpatient psychiatric unit for an acute manic episode and is started on haloperidol. On hospital day 4, she develops a fever of 39.4∘C39.4^\circ\text{C} (102.9∘F102.9^\circ\text{F}), severe muscle rigidity, and tachycardia. The floor nurse assumes these findings are related to psychiatric catatonia and does not notify the covering physician for four hours. When the physician eventually evaluates the patient, neuroleptic malignant syndrome is immediately recognized. The physician orders transfer to the intensive care unit and STAT administration of intravenous dantrolene. However, the hospital's medication distribution policy requires a multi-step, sequential approval process from the central pharmacy director to release rarely used emergency medications to psychiatric units. This policy delays the administration of dantrolene by an additional two hours. The patient subsequently develops acute kidney injury secondary to rhabdomyolysis.

Which of the following terms best categorizes the hospital's restrictive approval policy for emergency medications?

  1. A
    Active error
  2. Latent errorAnswer
  3. C
    Knowledge-based mistake
  4. D
    Near miss
  5. E
    Unpreventable adverse event

Answer

Latent error
The hospital's restrictive medication approval policy is a latent error (blunt-end error). Latent errors are systemic flaws embedded in the design, organization, policies, or environment of a healthcare system. They do not immediately cause harm on their own but create conditions that either allow active errors to occur or exacerbate the consequences of clinical emergencies. In this scenario, the bureaucratic policy structurally hindered the timely delivery of emergency care, making it a latent error.

Step-by-Step Solution

1
Analyze the clinical incident to identify the different types of failures that occurred during the patient's care.
Two main issues occurred: the nurse's delayed notification (an individual action) and the multi-step approval policy delaying medication (a system-level rule).
Distinguishing between the actions of individual frontline operators and the role of overarching system policies is essential for accurately categorizing medical errors.
2
Categorize the specific focus of the question, which is the hospital's restrictive medication approval policy.
The policy is a system-level organizational rule that hindered the timely delivery of emergency care at the 'blunt end' of the system.
System-level flaws that create conditions for harm, rather than direct actions by healthcare workers, meet the definition of a latent error.

Key Concept

Latent errors are systemic, organizational flaws (e.g., policies, structural design) that create conditions where active errors can occur or where patient harm is exacerbated.
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Topics

Classification of Medical Errors and Adverse Events

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