Match each clinical scenario describing a patient safety incident or outcome to the most appropriate error classification.
- A patient with no prior drug allergies develops severe anaphylaxis after receiving a correctly dosed, appropriately indicated intravenous antibiotic.Non-preventable adverse event
- A hospitalized patient sustains anoxic brain injury and falls into a coma after receiving a tenfold overdose of intravenous insulin due to a dosing miscalculation.Sentinel event
- A nurse notices that a unit of packed red blood cells is labeled with the wrong blood type during bedside verification, halting the transfusion before it begins.Near miss
- A patient develops a severe central line-associated bloodstream infection because the medical staff repeatedly bypassed sterile barrier precautions during catheter insertion.Preventable adverse event
Cevap
The scenarios match as follows: the unpreventable anaphylaxis is a non-preventable adverse event; the massive insulin overdose causing a coma is a sentinel event; the intercepted blood transfusion is a near miss; and the infection resulting from broken sterile protocols is a preventable adverse event.
Correctly categorizing safety events is essential for applying the proper quality improvement framework. Near misses reveal vulnerabilities without causing harm, providing a free opportunity to improve systems. Sentinel events signify catastrophic system failures requiring immediate Root Cause Analysis (RCA). Distinguishing between preventable and non-preventable adverse events determines where clinical practice guidelines need stricter enforcement.
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Patient Safety Event Classification
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