Match each clinical scenario or patient safety event to the most appropriate error classification.
- Active errorAn emergency department physician inadvertently intubates a patient's esophagus instead of the trachea during a code.
- Latent errorA hospital's central supply routinely places similar-appearing vials of epinephrine and local anesthetics in adjacent, poorly lit storage bins.
- Near missA resident mistakenly orders 50 mg of intravenous morphine instead of 5 mg, but the ward pharmacist intercepts the order before it is dispensed.
- Sentinel eventA patient admitted to the inpatient psychiatric unit for severe depression commits suicide by hanging in the hospital bathroom.
Cevap
Active error pairs with the physician intubation mistake. Latent error pairs with the medication storage flaw. Near miss pairs with the intercepted morphine order. Sentinel event pairs with the inpatient suicide.
Patient safety events must be categorized to guide the appropriate level of investigation and quality improvement. Active errors are direct actions by operators (sharp end). Latent errors are systemic vulnerabilities built into processes (blunt end). Near misses are errors caught before patient contact, providing free lessons for system improvement. Sentinel events involve catastrophic harm or death, requiring immediate mandatory reporting and root cause analysis.
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Anahtar Kavram
Classification of Medical Errors and Adverse Events