Recognition, reporting and analysis of adverse events — formative SAQs

SAQ 1 — Immediate response and systems model (10 marks)

A 4-year-old receives a ten-fold opioid infusion error. The nurse stops the pump. The child is drowsy but protecting the airway. No report has been filed. [1] [14]

Questions

1. Define adverse event, preventable adverse event and near miss. (3 marks) [5]
2. Outline your immediate clinical and safety actions in order. (4 marks) [1]
3. Explain latent conditions versus active failures using Reason’s model. (3 marks) [1]

Model answer

Definitions (3). An adverse event is unintended harm from health care rather than disease alone. A preventable AE could have been avoided with accepted practice. A near miss could have caused harm but did not. [5]

Immediate actions (4). Stabilise ABCs and reverse/support as indicated; keep the pump stopped and preserve settings/labels; escalate to senior help; assess for other exposed patients; document facts; notify family that an unexpected event occurred and care is focused on safety; report in the incident system. [1] [14]

Systems model (3). Active failures are sharp-end slips, lapses, mistakes or violations. Latent conditions are design, equipment, staffing and cultural holes that enable active failures. Harm occurs when defences align — Swiss-cheese thinking. [1]