Active Failure in Medication Administration
Administering a medication to the wrong patient (Option D) is considered an active failure. This represents a direct human error at the point of care that immediately impacts patient safety 1.
Understanding Active vs. Passive Failures
Active Failures
Active failures are errors made by frontline healthcare providers during direct patient care that have immediate consequences 1. These include:
- Wrong patient administration - violating the "five rights rule" (right medication, right dose, right time, right route, right patient) 1
- Wrong dose errors - miscalculation of dose, concentration, or infusion rate 1
- Substitution errors - syringe or ampule/vial swap 1
- Wrong route administration 1
- Omission or repetition errors 1
These are human actions that occur at the "sharp end" of care delivery and represent failures in active checking measures 1.
Passive/Latent Failures (System Failures)
The other options represent passive or latent system failures that create error-prone conditions 1:
- Option A (infusion pump without alerts) - represents inadequate safety technology and poor human-machine interface design 1
- Option B (look-alike medications in same bin) - represents a latent organizational failure in storage systems that creates error-provoking conditions 1
- Option C (barcode malfunction) - represents a passive system failure in error-reduction technology 1
Clinical Context
Preventing active failures requires active checking measures including medication preparation and administration by the same person, careful reading of labels, and strict application of the five rights rule 1. The anesthesia and critical care environment is particularly vulnerable because typically one provider handles prescribing, formulating, dispensing, and administering medications, removing the protection of double checks 1.
Common Pitfall
Do not confuse system-level deficiencies (latent conditions) with active failures. While system failures create the conditions for errors, the actual act of administering medication to the wrong patient is the active failure itself 1. Both require attention, but they demand different prevention strategies - active failures need behavioral interventions and checking procedures, while latent failures need system redesign 1.
Human and organizational factors, including interruptions during tasks, must be analyzed as they contribute to active failures at any step of the medication process 1.