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Zorluk: ZorClassification of Medical Errors and Adverse Events

Match each clinical incident summary to its most appropriate classification within the medical error and patient safety taxonomy.

  • A busy resident intends to order 10 mg of oral morphine but inadvertently selects '10 mg IV morphine' due to an attention lapse, despite knowing the correct equipotent conversions.Active error (Slip)
  • A provider prescribes an oral contraceptive to a 38-year-old woman who smokes 2 packs a day, misremembering the absolute contraindications for estrogen-containing products.Active error (Rule-based mistake)
  • A hospital's transition to a new electronic health record causes home medication lists to fail to auto-populate in the admission order set, leading to widespread delayed administrations of chronic medications.Latent error
  • A unit clerk incorrectly transcribes a patient's room number for a blood transfusion, but the nurse identifies the discrepancy during the mandatory two-identifier verification at the bedside.Near miss
  • A patient develops a severe, unpredictable idiosyncratic hepatotoxicity after three days of appropriately dosed isoniazid therapy for latent tuberculosis.Unpreventable adverse event

Cevap

The correct matches align the medication route error with Active error (Slip), the contraindicated prescription with Active error (Rule-based mistake), the EHR failure with Latent error, the intercepted blood transcription with Near miss, and the idiosyncratic hepatotoxicity with Unpreventable adverse event.
Each incident directly corresponds to a specific category in the patient safety taxonomy. Slips are action failures, mistakes are planning failures, latent errors are system flaws, near misses are intercepted errors, and unpreventable adverse events are unavoidable harms resulting from appropriate care.

Adım Adım Çözüm

1
Classify the incorrect morphine route order.
It is an Active error (Slip).
The provider knew the correct conversion but made an action-execution error due to an attention lapse, which defines a skill-based slip.
2
Classify the contraindicated oral contraceptive prescription.
It is an Active error (Rule-based mistake).
The provider applied flawed logic by forgetting a contraindication. Planning failures due to knowledge deficits are rule-based mistakes.
3
Classify the EHR medication list failure.
It is a Latent error.
This is an upstream, structural failure in the hospital system affecting multiple patients, acting as a systemic vulnerability at the blunt end of care.
4
Classify the intercepted blood transfusion transcription error.
It is a Near miss.
An error occurred but did not reach the patient because it was intercepted by a mandatory safety check.
5
Classify the idiosyncratic isoniazid hepatotoxicity.
It is an Unpreventable adverse event.
The medication was dosed appropriately, and the reaction was unpredictable. Harm from standard, appropriate care is an unpreventable adverse event.

Anahtar Kavram

Accurate classification of medical errors requires distinguishing between the sharp end (active errors: slips and mistakes), the blunt end (latent system errors), intercepted errors (near misses), and unavoidable harms (unpreventable adverse events).
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Classification of Medical Errors and Adverse Events

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