Match each clinical incident summary to the most accurate classification of medical error or adverse event.
- A patient receives a toxic medication dose because the hospital's pharmacy software defaults to milligrams instead of micrograms for pediatric weight-based calculations.Latent error
- A resident physician, fatigued at the end of a 24-hour shift, accidentally clicks the wrong patient's name in the electronic health record and orders an unnecessary laboratory test.Active error
- A nurse is about to administer a unit of packed red blood cells to a patient but notices that the blood bank label does not match the patient's wristband, stopping the transfusion.Near miss
- An admitted psychiatric patient dies by suicide in their hospital room due to a failure of staff to adhere to the required 15-minute observation protocol.Sentinel event
- A patient with normal baseline renal function and no known risk factors develops contrast-induced nephropathy following an indicated computed tomography angiogram.Unpreventable adverse event
Cevap
The incidents correspond to a latent error (system flaw), active error (frontline mistake), near miss (intercepted error), sentinel event (severe unexpected harm), and unpreventable adverse event (complication despite standard care), respectively.
Each incident strictly corresponds to a distinct category in the patient safety taxonomy. Systemic vulnerabilities are latent errors; frontline mistakes are active errors; intercepted potential harm is a near miss; severe, unexpected harm or death is a sentinel event; and complications occurring despite standard care are unpreventable adverse events.
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Anahtar Kavram
Classification of Medical Errors and Adverse Events