Match the following clinical scenarios related to patient safety events with their correct event classification and appropriate administrative pathway.
- A pharmacist intercepts an electronic order for a 10-fold overdose of insulin before the medication is dispensed to the nursing unit.Near miss: The event did not reach the patient; requires internal incident reporting to identify and mitigate process vulnerabilities.
- A nurse administers an incorrect medication to a patient because two different drugs with look-alike packaging were stocked adjacently in the automated dispensing cabinet.Latent condition: An underlying systemic vulnerability in design or organization facilitated the error; requires system-level review and redesign.
- A physician manually overrides a medication allergy alert in the electronic health record and prescribes penicillin to a patient with a documented severe allergy, causing anaphylaxis.Active failure: A direct unsafe act committed by frontline personnel at the point of care; requires individual feedback and review of adherence to safety protocols.
- A patient undergoes a surgical procedure on the wrong extremity due to a failure to perform a pre-operative time-out, resulting in permanent loss of function.Sentinel event: An unexpected occurrence involving death or serious physical injury; mandates immediate comprehensive root cause analysis and often regulatory reporting.
Cevap
The intercepted insulin order matches with Near miss. The look-alike medication storage matches with Latent condition. The alert override matches with Active failure. The wrong-site surgery matches with Sentinel event.
Patient safety events are categorized to guide appropriate institutional responses. Near misses highlight vulnerabilities before harm occurs. Latent conditions are systemic issues like poor storage or confusing packaging. Active failures are direct errors by frontline staff. Sentinel events are severe, unexpected harms like wrong-site surgery that require immediate reporting and root cause analysis.
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Anahtar Kavram
Classification of Patient Safety Events