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]

SAQ 2 — Detection, disclosure and learning (10 marks)

A unit celebrates “zero incidents” based only on voluntary reports. A registrar is distressed after a serious event. Families ask what will change. [11] [13] [15]

Questions

1. Why is voluntary reporting alone a weak safety metric? (3 marks) [11]
2. State open disclosure principles families expect. (3 marks) [14]
3. Name two strong system actions after a handoff-related AE and one second-victim support step. (4 marks) [13] [15]

Model answer

Detection (3). Classen showed trigger-tool methods detect far more AEs than voluntary reporting implies; “zero reports” may mean silence, not safety. [11]

Disclosure (3). Explain what happened, what it means for the child, what is being done now, apology as appropriate, and how the family can reach the team — honesty is valued. [14]

Actions and support (4). Strong actions include structured handoff programmes (Starmer showed medical-error reduction) and system standardisation/forcing functions; weak action is posters alone. Support the second victim with peer support and temporary relief from high-risk tasks if needed. [13] [15]