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 |