Application of the taxonomy
| Case 1 | |
| “Yesterday I saw a girl who had been followed for five years by a gastroenterologist for constipation. In the last year and a half it had been noted that she had not gained any weight at all … The gastroenterologist did a lot of tests, very focused on looking to exclude the diagnosis of inflammatory bowel. I saw her yesterday, did some simple tests, and it became quite clear that her kidneys were not working at all as they should be. A very simple urine test would have picked this up months ago.” | |
| Domain of medicine | Diagnostics |
| Problem type | Human action: problematic decision |
| Contributing factors | |
| Patient/child specific factors | Physiological development |
| Human factors | Cognitive |
| Latent conditions | Structure |
| Outcome | |
| Outcome | Delayed growth |
| Level of harm | Major temporary |
| Case 2 | |
| “Patient [was] prescribed a medication that the patient was known to be allergic [to] … [the patient has a] past history of rash. The prescription was filled but the [allergy] was noted prior to giving the medication to the patient.” | |
| Domain of medicine | Medication ordering: wrong medication |
| Problem type | Human action: problematic decision |
| Contributing factors | |
| Patient/child specific factors | None |
| Human factors | Physical |
| Latent conditions | Medication systems |
| Outcome | |
| Outcome | Near miss |
| Level of harm | No harm, good catch |
| Case 3 | |
| “We had a medication error … it was a new nurse. We pretty much have a flat out chart and it’s pretty self-explanatory. It’s fantastic stuff, like what to do, how much is in there, what to run it at—it’s an excellent chart. And any [patient] over 30 kg gets 1 cc of Isuprel in a 50 cc bag. So less than 30 kg, it is all charted out. So it was a less than 30 kg baby, but she was out of the habit because the majority of our kids that we do with SVT are greater than 30 kg … So when we had someone less than 30 [kg], she knew to go to the chart, but out of pure habit, she just put the cc in there and the kid had extra Isuprel.” | |
| Domain of medicine | Medication administration: wrong concentration |
| Problem type | Human action: problematic execution |
| Contributing factors | |
| Child specific factors | Variable size and morphology |
| Human factors | Cognitive |
| Latent conditions | Medication systems |
| Outcome: | |
| Medical outcome | 3× overdose |
| Level of harm | Minor temporary harm |
| Case 4 | |
| “… A case of a child with a large … [abdominal] tumor, a vessel arising apparently from the chamber that appeared to be an … artery, appeared to flow right into the tumor directly and it was pulsating and it was a vessel that appeared to be the [artery we were trying to ligate] … we had come around to the medial side and got control of the artery and the vein … to ligate them and take them out … that would allow those vessels to be divided which will allow the [organ] to be elevated … The vessel was identified. The senior pediatric surgical fellow was my assistant…very experienced for this procedure … We both tracked this vessel out, started going to the [organ], tracked it back to the point of origin, and we were convinced that it was the artery we thought it was. We ligated it, we immobilized the [organ] … So this vessel that we thought was arising from the aorta … was actually the superior mesenteric artery … so the artery was divided. Upon release of the [organ] and of the mass, it was apparent that the orientation of the aorta and this vessel was not what I thought it was.” | |
| Domain of medicine | Procedure |
| Problem type | Human action: problematic execution |
| Contributing factors | |
| Child specific factors | None |
| Human factors | Cognitive |
| Latent conditions | Systems |
| Outcome | |
| Medical outcome | Cut wrong vessel |
| Level of harm | Major temporary |