Table 1

Adverse Medical Event System

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
TechnicalRefers to equipment, physical installation, material, labels, forms, etc
    ExternalTechnical failures beyond control of investigating organization
    DesignInadequate design of equipment and related support material
    ConstructionCorrect designs were not constructed properly
    MaterialsMaterial defects
    ExternalFailures beyond control of investigating organization
    ProceduresPoorly or inadequately designed protocols
    KnowledgeFailure of transfer of knowledge or information to staff
    ManagementInternal decision to relegate safety decision to an inferior position
    CultureCollective failure and its attendant modes to function safely
Active errors Errors or failures that result from human behavior
ExternalHuman failures beyond control of organization
KnowledgeInability to apply existing knowledge to novel situation
Rule based
    QualificationsIndividual not qualified by education or training for task
    CoordinationLack of task coordination within healthcare team
    VerificationIncomplete assessment of situation
    InterventionFailures that result from faulty task planning and execution
    MonitoringFailure to monitor process or patient
Skill based
    “Slip”Failure in performance of highly developed skill
    “Trip”Failure in whole body movement
OtherFailure in patient beyond control of organization