Adverse Medical Event System
| Category | Description |
|---|---|
| System based on Eindhoven classification model as modified by Medical Event Reporting System for transfusion medicine.19 | |
| Latent errors | Errors that result from underlying system failure |
| Technical | Refers to equipment, physical installation, material, labels, forms, etc |
| External | Technical failures beyond control of investigating organization |
| Design | Inadequate design of equipment and related support material |
| Construction | Correct designs were not constructed properly |
| Materials | Material defects |
| Organizational | |
| External | Failures beyond control of investigating organization |
| Procedures | Poorly or inadequately designed protocols |
| Knowledge | Failure of transfer of knowledge or information to staff |
| Management | Internal decision to relegate safety decision to an inferior position |
| Culture | Collective failure and its attendant modes to function safely |
| Active errors | Errors or failures that result from human behavior |
| External | Human failures beyond control of organization |
| Knowledge | Inability to apply existing knowledge to novel situation |
| Rule based | |
| Qualifications | Individual not qualified by education or training for task |
| Coordination | Lack of task coordination within healthcare team |
| Verification | Incomplete assessment of situation |
| Intervention | Failures that result from faulty task planning and execution |
| Monitoring | Failure to monitor process or patient |
| Skill based | |
| “Slip” | Failure in performance of highly developed skill |
| “Trip” | Failure in whole body movement |
| Other | Failure in patient beyond control of organization |