From the Guidelines
The answer is B. Latent error. This situation represents a latent error because the anaesthetist created conditions that could potentially lead to a medication error, even before any actual mistake occurred. By placing two different medications with identical physical appearances (same shape and color) on the drug preparation shelf, the anaesthetist established a system vulnerability that increases the risk of medication mix-up. Latent errors are hidden flaws in the system that may remain dormant until they combine with other factors to breach safety defenses.
Key Points to Consider
- In healthcare settings, proper medication management requires distinguishing between different drugs through clear labeling, color-coding, or physical separation to prevent confusion, as emphasized by 1.
- The use of international color coding of labels for syringes and medication storage devices, as well as careful reading of labels before administration, can help prevent medication errors, as noted in 1.
- Limiting the list of medications delivered and avoiding similarities in shape, color, and name are also crucial in preventing errors, as highlighted in 1.
- Addressing latent errors requires system-level interventions like standardized medication storage protocols and awareness of look-alike/sound-alike medication risks.
Prevention Strategies
- Implementing protocols for preparing and administering medications can help minimize errors.
- Regular involvement of a pharmacist in the unit and the use of programmable power syringes connected to a computer can also enhance safety, as mentioned in 1.
- High levels of vigilance for sedative and vasoactive agents, which are commonly involved in medication errors, are essential in critical care settings. This type of error differs from a medication error (which would be the actual administration of the wrong drug) or an anaesthesia error (which would be a broader category of mistakes specific to anaesthetic practice).
From the Research
Medication Error
- A medication error occurs when a patient receives the wrong medication, the wrong dose, or the medication is administered incorrectly 2.
- In the given scenario, an anaesthetist putting two different medications of the same shape and colour on a drug preparation shelf can lead to a medication error if the wrong medication is administered to the patient.
- This type of error is specifically referred to as a medication error, which can have serious consequences for the patient.
Latent Error
- A latent error refers to a mistake that is inherent in the design or organization of a system, rather than a mistake made by an individual 2.
- While the anaesthetist's action of putting two different medications of the same shape and colour on a drug preparation shelf can contribute to a medication error, it is not necessarily a latent error.
- Latent errors are often related to systemic or organizational issues, rather than individual mistakes.
Anaesthesia Error
- An anaesthesia error refers to a mistake made during the administration of anaesthesia, which can have serious consequences for the patient.
- While the scenario involves an anaesthetist, the error is more specifically related to medication administration rather than anaesthesia administration.
- Therefore, the correct term for the error in this scenario is a medication error, rather than an anaesthesia error.
The correct answer is A. Medication error.