Review the following events and system vulnerabilities related to hospital safety. Align each specific clinical or administrative scenario with its most accurate patient safety classification.
- Latent error (System vulnerability)An institutional policy mandates the use of lower-cost surgical marking pens that easily wash off during standard skin prep, predisposing teams to wrong-site surgery.
- Sentinel eventA hospitalized patient dies unexpectedly from asphyxiation after becoming wedged between the mattress and a defective bed side rail.
- Active error (Sharp-end failure)A hurried cross-covering intern manually calculates a medication dosage using pounds instead of kilograms, entering a supratherapeutic dose into the chart.
- Near miss (Close call)A nurse prepares to administer a contraindicated medication but recognizes the error during bedside barcode scanning and discards the syringe before patient contact.
Answer
Latent error matches with the procurement of flawed surgical pens; Sentinel event matches with the unexpected bed rail asphyxiation; Active error matches with the intern's weight-based calculation mistake; Near miss matches with the intercepted contraindicated medication.
Each scenario maps to a distinct concept in the Swiss Cheese Model of accident causation and standard patient safety terminology. Latent conditions are organizational or structural defects at the blunt end. Active failures are point-of-care errors at the sharp end. A near miss is an intercepted error that did not reach the patient, while a sentinel event is a severe, unexpected outcome involving death or serious physical or psychological injury.
Step-by-Step Solution
Key Concept
Classification of medical errors and safety events (e.g., latent vs. active errors, near misses, sentinel events) is foundational for root cause analysis and systems improvement.