What is the term for an error caused by an anaesthetist (anesthesiologist) placing two different medications with the same shape and colour on a drug preparation shelf?

From the Guidelines

The answer is B. Latent error. This situation represents a latent error because it involves a system-level flaw in medication storage that creates conditions where mistakes are more likely to occur. When an anesthetist places two different medications with identical physical appearances (same shape and color) on the same preparation shelf, they create a hidden trap in the workflow. This error doesn't immediately cause harm but establishes conditions where a subsequent active error (selecting the wrong medication) becomes much more likely. According to the study by 1, preventing medication errors in anesthesia and critical care requires a combination of active checking measures and passive measures, such as labeling and mechanical systems, to minimize opportunities for errors, particularly substitution errors. Some key measures to prevent such errors include:

• International color coding of labels for syringes and medication storage devices 1
• Careful reading of labels before administration 1
• Application of the five-rights rule (right medication, in the right dose, at the right time, via the right route, to the right patient) 1
• Limiting the list of medications delivered and avoiding similarities in shape, color, and name 1 These measures can help reduce the risk of latent errors and subsequent medication errors in anesthesia and critical care settings.

From the Research

Medication Error Classification

• The scenario described, where an anaesthetist puts two different medications of the same shape and colour on a drug preparation shelf, leading to a potential error, is an example of a:
  • Medication error 2, 3, 4, 5, 6

Error Types

• Medication errors can occur due to various factors, including:
  • Similarity in medication appearance (shape and colour)
  • Inadequate labelling or packaging
  • Human error (e.g., distraction, fatigue)

Latent Errors

• Latent errors refer to underlying system flaws or design issues that can contribute to errors, such as:
  • Inadequate medication storage or handling procedures
  • Insufficient training or education for healthcare professionals
  • Poor communication or teamwork

Anaesthesia Errors

• Anaesthesia errors are a specific type of medication error that can occur during the administration of anaesthetics, such as:
  • Incorrect dosage or administration route
  • Inadequate monitoring or patient assessment
  • Failure to follow established protocols or guidelines