Medical error: an action or failure to act that exposes a patient to possible harm in the context of medical care, regardless of whether or not harm actually occurs; focuses on the process (the misstep or omission).
Adverse event: an unintended harmful consequence of a medical treatment, which may or may not be the result of a medical error; focuses on the outcome (actual harm done to the patient).
Classification of medical errors
Active error
Occurs at level of frontline operator (eg, wrong IV pump dose programmed)
Immediate impact
Latent error
Occurs in processes indirect from operator but impacts patient care (eg, different types of IV pumps used within same hospital)
Accident waiting to happen
Classification of adverse events
Preventable adverse event
Any adverse event that is due to a medical error
A patient is given a medication to which they are allergic because their allergy information was never documented in the chart.
Ameliorable adverse event
An unpreventable adverse event that could have been reduced in severity through specific actions
A patient’s correctly placed IV subsequently becomes infiltrated (unpreventable), but this is not discovered for a number of hours because of understaffing
Never event
Adverse event that is identifiable, serious, and usually preventable (eg, scalpel retained in a surgical patient’s abdomen)
Major error that should never occur
Sentinel event—a never event that leads to death, permanent harm, or severe temporary harm
Their occurrence can reveal vulnerabilities in the healthcare system
Near miss
Unplanned event that does not result in harm but has the potential to do so (eg, pharmacist recognizes a medication interaction and cancels the order)
Narrow prevention of harm that exposes dangers
Management of medical errors
Initial disclosure
Acknowledge errors openly
Do not hide errors or other relevant factors
Express empathy & give apology as appropriate
Avoid blaming or denigrating other team members & providers