Join the ‘Latent Error Of The Week Challenge’ #LEOTWC
Latent Error = Hole in the Piece of Cheese, that piece of equipment or system hazard that is sat waiting to contribute to an adverse event.
Scores – maximum 31
Made up from
A. How well described & random the latent error is /10
B. How severe the predicted adverse event could be /10
C. How effective your measures to remove it are /11 (this is where the money is – there’s no point in reporting a latent error if we don’t put something effective in place to remove it)
Anonymous (no patient / staff / institution names please)
It doesn’t sit well with us either but we’re desperate to get rid of these latent errors (think Sixth Sense – ‘We see latent errors and they’re everywhere’). Please help.
We’ll start off:
Dexamethasone and Droperidol in almost identical vials stored next to each other in anaesthetic drug trolley
A. 3/10 picture reasonable, could have shown them in trolley, iphone3s
B. 3/10 bad if patient known to be allergic to one or other otherwise both good for PONV
C. 2/10 pulled all stock out of that theatre drug trolley, told anaesthetic nurse to report it to nurse in charge, found out this was now the new formulation of Droperidol being stocked in the hospital, suggested drugs be kept well apart on drug trolley, felt a bit frustrated, sighed, pretty piss poor really.
Total 8/31 (crapola)
See if you can beat it.