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Table 1 Error Classifications

From: Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load

Classification

Definitions

Examples

Error

Procedural error in the preparation or use of medications or equipment with the potential to result in harm.

Medication:

Syringe containing anaesthesia medication labelled incorrectly or not labelled

Incorrect medication administered

Incorrect dose administered

Equipment:

Sharps injury

Procedure performed not in accordance with SOP (i.e. checklist not used, bougie not used)

Lapse

A failure to execute an action due to lapse in memory and a routine behaviour being omitted.

Medication preparation:

Same needle used to draw up multiple medications

No syringe cap

Unsafe sharps management

Equipment preparation:

Cuff of tracheal tube not checked

Laryngoscope bulb operation not checked

No bougie