A root cause analysis committee is reviewing several adverse events and near misses. To identify targeted mitigation strategies, each event must be correctly mapped to its underlying cognitive or systemic failure mode. Correlate the following event scenarios with their most precise classification in the human factors and medical error taxonomy.
- A physician correctly diagnoses a deep vein thrombosis in a pregnant patient but prescribes warfarin instead of low-molecular-weight heparin, automatically applying a familiar treatment algorithm while failing to incorporate the patient's pregnancy status into the decision.Rule-based mistake
- An intern encounters a patient with a rare toxicological ingestion not covered in their training. They attempt to derive a novel management plan from basic physiological principles, but inadvertently administer an agent that exacerbates the toxicity.Knowledge-based mistake
- An anesthesiologist intends to administer 1 mg of midazolam. While simultaneously watching the patient's vital signs monitor during the injection, they inadvertently push the syringe plunger too far and deliver 2 mg.Action-based slip
- A hospitalist plans to order a CT angiogram, an ECG, and troponins for a patient. After being interrupted by an urgent page, the hospitalist returns to the workstation, orders the CT and troponins, but forgets to enter the ECG order.Memory-based lapse
- The hospital purchasing department switches to a new vendor for intravenous lines. The new IV tubing is physically compatible with epidural catheters, creating a hazard for accidental intrathecal administration of intravenous medications.Latent system failure
Cevap
The warfarin in pregnancy error maps to a rule-based mistake. The rare toxicology error maps to a knowledge-based mistake. The midazolam overdose maps to an action-based slip. The forgotten ECG maps to a memory-based lapse. The IV tubing compatibility maps to a latent system failure.
Based on James Reason's taxonomy and Jens Rasmussen's SRK framework, errors are divided into execution failures (slips and lapses) and planning failures (mistakes). Slips are action-based failures of attention. Lapses are memory-based failures of retrieval. Mistakes are failures of intention, further divided into rule-based (applying the wrong protocol to a known situation) and knowledge-based (failing to problem-solve a novel situation). Latent failures represent organizational vulnerabilities rather than direct cognitive failures.
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Anahtar Kavram
Cognitive Error Taxonomy and the Skill-Rule-Knowledge (SRK) framework