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Zorluk: OrtaClassification of Medical Errors and Adverse Events

A 74-year-old woman is admitted to the hospital for the management of newly diagnosed nonvalvular atrial fibrillation. Her past medical history is significant for hypertension and advanced chronic kidney disease. The admitting physician decides to initiate anticoagulation and enters an order for dabigatran at the standard dose of 150 mg twice daily. The patient's most recent comprehensive metabolic panel, drawn earlier that day at an affiliated outpatient clinic, shows a creatinine clearance of 22 mL/min. However, because this lab result was manually scanned into the "Media" tab of the electronic health record rather than populating as discrete data, the computerized provider order entry (CPOE) system's automated renal dosing alert fails to trigger. Thirty minutes later, the clinical pharmacist verifying the orders manually reviews the scanned documents, identifies the severe renal impairment, and contacts the physician. The physician immediately cancels the dabigatran order and prescribes renally adjusted apixaban instead. The patient receives the apixaban and experiences no complications. Which of the following patient safety classifications best describes this sequence of events?

  1. Near missCevap
  2. B
    Preventable adverse event
  3. C
    Unpreventable adverse event
  4. D
    Sentinel event
  5. E
    Diagnostic error

Cevap

The correct classification is a near miss.
The correct classification is a near miss (also known as a close call). A near miss is defined as an unsafe act (active error) or a latent system vulnerability that had the potential to cause patient harm but failed to do so because it was intercepted by a robust defense mechanism (in this case, the pharmacist's manual review) or by chance. The physician ordered a medication that was contraindicated for the patient's level of renal function, and the CPOE system failed to alert the physician due to a latent flaw in how outside labs were recorded. However, because the error was caught before the drug was dispensed and administered, the patient suffered no harm, precisely fitting the definition of a near miss.

Adım Adım Çözüm

1
Analyze the physician's action and the system's role.
An active error occurred (prescribing a contraindicated dose) compounded by a latent system error (scanned labs not triggering the CPOE alert).
Identifying the types of errors involved is the first step in classifying the overall event.
2
Determine if the error reached the patient.
The clinical pharmacist intercepted the error before the medication was dispensed or administered.
The distinction between an adverse event and a near miss depends entirely on whether the error reached the patient.
3
Assess for patient harm.
No harm occurred because the patient received the correct, modified medication.
Adverse events and sentinel events require actual patient harm, whereas a near miss involves an intercepted error with no harm.

Anahtar Kavram

Classification of Patient Safety Events
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Konular

Classification of Medical Errors and Adverse Events

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