Match each of the following clinical and organizational scenarios with the most appropriate patient safety classification.
- During a preoperative timeout, the circulating nurse notes that the consent form specifies a left-sided procedure, but the surgical schedule lists the right side. The procedure is paused until the discrepancy is resolved.Near miss
- An inpatient commits suicide in a locked psychiatric unit using an improperly secured curtain cord.Sentinel event
- A resident physician, experiencing severe fatigue at the end of a 28-hour shift, accidentally programs an intravenous infusion pump for 500 mL/hr instead of the intended 50 mL/hr.Active error
- A hospital's electronic health record defaults to an adult weight-based dosing algorithm even when a pediatric patient's chart is open, requiring clinicians to manually override the settings.Latent error
Cevap
Preoperative timeout discrepancy matches Near miss; Inpatient suicide matches Sentinel event; Pump programming mistake matches Active error; EHR default dosing flaw matches Latent error.
Patient safety frameworks categorize adverse events to determine the appropriate response and root cause. A near miss is an intercepted error that did not reach the patient. A sentinel event is a severe, unexpected outcome (such as inpatient suicide) requiring immediate root cause analysis. Active errors are frontline human errors (slips, lapses, mistakes), while latent errors are underlying system or organizational defects (like faulty EHR defaults) that facilitate active errors.
Adım Adım Çözüm
Anahtar Kavram
Patient Safety and Medical Error Classifications