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Zorluk: KolayClassification of Medical Errors and Adverse Events

A 65-year-old man is admitted to the hospital with community-acquired pneumonia. The admitting resident physician orders intravenous ceftriaxone. The patient has a well-documented history of severe anaphylaxis to cephalosporins in his electronic health record. Due to a recent software update glitch, the system fails to trigger an allergy alert on the physician's screen. However, a clinical pharmacist reviewing the medication orders notices the documented allergy and immediately contacts the physician. The order is cancelled before the medication is dispensed from the pharmacy. The patient receives an alternative antibiotic and recovers without issue.

Which of the following terms best classifies this event?

  1. Near missCevap
  2. B
    Sentinel event
  3. C
    Preventable adverse event
  4. D
    Unpreventable adverse event
  5. E
    Active error with patient harm

Cevap

Near miss
The event described is a near miss (also known as a close call). A near miss is defined as an error or incident that could have resulted in harm to a patient but did not, either by chance or by timely intervention. In this scenario, the pharmacist's intervention prevented the contraindicated antibiotic from reaching the patient.

Adım Adım Çözüm

1
Analyze the clinical scenario for the presence of a medical error and patient harm.
An active error occurred (prescribing a contraindicated antibiotic) along with a latent system error (alert failure), but the medication was never given. No harm occurred.
Identifying the error and the presence or absence of harm is required to classify the event correctly.
2
Determine if the error reached the patient.
The clinical pharmacist intercepted the error before the medication was dispensed or administered.
Events that do not reach the patient belong to a specific safety category.
3
Apply standard patient safety terminology to the event outcome.
An event that could have resulted in harm but did not reach the patient due to timely intervention is defined as a near miss (or close call).
This directly matches the definition of a near miss.

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Classification of Medical Errors and Adverse Events
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Classification of Medical Errors and Adverse Events

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