Match each of the following clinical scenarios to the most appropriate patient safety error classification.
- A physician orders an incorrect dose of intravenous heparin. Before the medication is administered, a nurse identifies the discrepancy during a routine double-check and discards the syringe.Near miss (close call)
- A hospital's intravenous infusion pumps feature poorly designed interfaces that require navigating multiple confusing sub-menus to adjust dosages, continuously predisposing nursing staff to programming mistakes.Latent error (blunt-end error)
- A resident physician rapidly inputs an order for penicillin without reviewing the electronic chart. The patient, who has a documented penicillin anaphylaxis history, receives the dose and develops mild urticaria.Active error (sharp-end error)
- Following a failure to mark the surgical site and the surgical team's bypass of the mandatory preoperative timeout, a patient undergoes a total knee arthroplasty on the wrong leg.Sentinel event
Cevap
The intercepted heparin error matches with 'Near miss'; the poorly designed pump interface matches with 'Latent error'; the administered penicillin causing a rash matches with 'Active error'; and the wrong-site surgery matches with 'Sentinel event'.
Each scenario accurately depicts a fundamental category of medical error in patient safety terminology. A near miss is an error caught before reaching the patient. A latent error is a systemic flaw that predisposes staff to mistakes. An active error occurs at the frontline of care. A sentinel event is a severe, unexpected outcome that requires immediate institutional response.
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Anahtar Kavram
Classification of medical errors and adverse events in patient safety