A hospital's quality improvement committee is reviewing several documented patient safety incidents to classify them according to established safety terminology. Match each clinical scenario with the most accurate error classification.
- A hospital's electronic health record system defaults to ordering an adult medication dosage for pediatric patients due to an unrecognized programming flaw.Latent error
- A pharmacist intercepts a critically high dose of intravenous potassium chloride prescribed by a resident before it reaches the ward.Near miss (close call)
- An anesthesiologist intends to administer an antiemetic but inadvertently grabs a similarly labeled syringe of a paralytic agent and administers it.Active error (slip)
- A patient undergoes a routine appendectomy but suffers a retained surgical sponge, resulting in an unexpected death from sepsis.Sentinel event
Cevap
EHR flaw aligns with Latent error; Intercepted medication aligns with Near miss; Wrong syringe administration aligns with Active error; Retained sponge causing death aligns with Sentinel event.
Each incident perfectly illustrates a foundational concept in patient safety. The EHR programming flaw is a systemic vulnerability (latent error). The intercepted medication is a prevented harm (near miss). The wrong syringe grab is an execution failure at the sharp end of care (active error). The death from a retained sponge is a severe, unexpected outcome requiring immediate investigation (sentinel event).
Adım Adım Çözüm
Anahtar Kavram
Classification of Patient Safety Incidents