Match each of the following clinical incident scenarios to the most appropriate patient safety event classification category.
- A 28-year-old man with no documented medical history receives appropriately dosed prophylactic cefazolin prior to hernia repair and rapidly develops anaphylactic shock.Unpreventable adverse event
- A pediatric patient is prescribed an oral suspension of amoxicillin, but the pharmacy technician prepares it at ten times the intended concentration; the bedside nurse notices the discrepancy before administration.Near miss (Close call)
- A 55-year-old woman undergoes a total abdominal hysterectomy; due to a bypassed surgical counting protocol, a laparotomy pad is inadvertently left inside her abdomen, requiring an emergent second operation.Sentinel event
- A 70-year-old man with known severe asthma is incorrectly prescribed a nonselective beta-blocker for hypertension, leading to a severe asthma exacerbation requiring hospitalization.Preventable adverse event
Cevap
The cefazolin-induced anaphylaxis is an unpreventable adverse event. The intercepted medication error is a near miss. The retained laparotomy pad is a sentinel event. The asthma exacerbation caused by a contraindicated beta-blocker is a preventable adverse event.
The correct matches rely on identifying whether an error occurred, whether it reached the patient, and the severity of the outcome. A near miss is an error intercepted before patient harm. A preventable adverse event involves harm caused by an error (e.g., contraindicated drug). An unpreventable adverse event involves harm from appropriate care (e.g., first-time allergic reaction). A sentinel event involves unexpected death or severe physical/psychological harm, strictly including 'never events' like retained surgical items.
Adım Adım Çözüm
Anahtar Kavram
Classification of patient safety events depends on whether an error occurred, whether the error reached the patient, and the severity of the resulting harm.